MS neuro original
A mother brings her 6-year-old to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?
"A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."
The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm?
"Your physician wants to evaluate the location and condition of the aneurysm."
A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam (Valium) 0.25 mg/kg. How many milligrams will be given to this client?
15 mg
A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, which deficits are anticipated?
A delayed reaction in response due to the interrupted impulses from the central nervous system
When using pharmacologic aids to assist with bowel training, which aid would the nurse anticipate to be used first?
A glycerin suppository
The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate to the nurse that the client is in a semicomatose state?
A score of 9
A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy?
Anticipate need for endotracheal intubation.
A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client?
Assess neurological findings.
A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
Avoid heavy lifting.
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
Body temperature
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?
Brain tumor
A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of cell transplantation therapy. Which early outcome of treatment is anticipated?
Cell transplantation therapy allows the replacement of nerve cells that are damaged
The critical care nurse is giving report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?
Comatose
The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of accident. The nurse provides all details to the next shift and is most accurate to report which type of injury?
Contrecoup injury
A client with atrial fibrillation is placed on Coumadin to reduce the potential of developing a cerebrovascular accident (CVA). The international normalized ratio (INR) is 1.5. What does this finding indicate to the nurse?
Coumadin will be increased.
The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae with bone from which location?
Iliac crest
The nurse is caring for a 55-year-old client on a rehabilitated unit following a cerebrovascular accident (CVA). The nurse is instructing on range of motion exercises when the client begins to cry. The client states she has always taken care of the family and does not want to be a burden. Which nursing diagnosis would the nurse add to the plan of care?
Ineffective Role Performance related to inability to function in family role
The nurse is caring for a client with paraplegia in the acute care setting. The client's last bowel movement was 4 days ago. Which nursing action is best to assist the client in accomplishing the goal of an enema?
Instill the enema slowly (1 to 2 oz at a time) followed by a waiting period.
You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside?
Intubation tray and suction apparatus
You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has?
Ischemic
A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility?
Keep the client hydrated.
A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply.
Left-sided hemiplegia, tedency to distractibility, neglect of objects and people on the left side
Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?
Lethargy
The nurse is instructing the paralyzed client on a method to stimulate the relaxation of the urinary sphincter aiding in urinary elimination. Which instruction would be correct?
Lightly massage or tap the skin above the pubic area.
A client presents to the emergency department status postseizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client?
Lumbar puncture
Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease?
Maintaining a safe environment
Which of the following would the nurse include in the rationale for the nursing intervention to maintain body alignment? Select all that apply.
Maintaining body alignment prevents contractures, maintaining body alignment decreases pain
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
Mannitol (Osmitrol)
A 58-year-old client has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identified potential causes of the pain. Which area of the drawing would the nurse emphasize?
Nucleus pulposus
The nurse is caring for a client who was discovering unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?
Observe for any signs of behavioral changes.
The nurse is caring for a client with neurologic deficits who is interested in implementing a bowel training program. Which of the following does the nurse identify as the first step?
Recording bowel movements
What phase of a neurologic deficit begins when the client's condition is stabilized?
Recovery
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?
Subdural
Which nursing assessment finding is most indicative of a hemorrhagic stroke?
Sudden onset of breathing alterations
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?
Suicidal ideations
The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?
Sympathetic nervous system
The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?
The client grasps the affected arm at the wrist and raises it.
The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
The client has cerebral spinal fluid (CSF) leaking from the ear.
A critical care nurse is documenting her assessment of a client she is caring for. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean?
The client is not responding to stimuli.
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
The client will remain free of injury if a seizure does occur.
A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse?
The client's medications include warfarin (Coumadin).
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
Traction with weights and pulleys
The brain stem holds the medulla oblongata. What is the function of the medulla oblongata?
Transmits motor impulses from the brain to the spinal cord
A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA?
Unilateral ptosis
A client with increased intracranial pressure is receiving mannitol (Osmitrol) via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment?
Urine output is increased.
A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply.
baloon angioplasty of the carotid artery followed by stent placement, carotid endarterectomy
The nurse is caring for a client with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Select all that apply.
bone demineralization, contractures, spasticity, limited range of motion
Which of the following occupations are anticipated to improve the functioning of a client with a neurologic deficit? Select all that apply.
occupational therapist, speech therapist, neurologist, physical therapist
A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of TPA in a client with CVA requires which of the following? Select all that apply.
presence of an ischemic stroke, administer within 3 hours of onset of symptoms
The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply.
red wine, menstruation
The client with Guillain-Barré syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome?
"Antibodies that triggered the autoimmune response are removed from your blood."
A client, with a recent closed head injury, began experiencing partial (focal) seizures and asks the nurse to explain why this is happening. Which is the best response from the nurse?
"It is not uncommon for seizure activity to occur after head trauma."
The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?
Cranial nerve XII
You are caring for a client with an inoperable brain tumor. What is a major threat to this client?
Increased ICP
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?
Administer medications at exact intervals ordered.
The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious stating, "What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain." The nurse is most correct to turn the teaching to which surgical procedure?
A spinal fusion
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following?
Anticoagulant therapy
The nurse is assisting in the discharge process where a female, paralyzed client is returning home with her husband and two children. Which of the following prescription classifications, used prior to hospitalization, is most important to relate to the physician when discharging?
Birth control pills
You suspect that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply.
Bladder distention, poiklothermia, no perspiration below the level of injury
Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment?
Blood pressure
A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?
Brain CT scan or MRI
A client is prescribed warfarin. Client teaching has included instructions to avoid a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to avoid?
Cereals, soybeans, and spinach
The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
Cerebral angiography
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?
Cerebrospinal fluid is cloudy in nature.
Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area?
Computed tomography (CT)
The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?
Conception is not impaired; the birth process is determined with the physician.
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?
Damage to the nerves that facilitate vision and hearing
The nurse is caring for a client with dysphagia. Which instruction to the family is most important?
Do not open/crush a medication in a capsule.
A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?
Flaccidity
An emergency department nurse is admitting a client brought in by the paramedics after falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client?
Goal is to stabilize the client and prevent further neurologic damage.
A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client?
Grade V on the Hunt-Hess Scale
The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse is correct to instruct on the action of which system?
Sympathetic nervous system
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest?
Take small meals of nutrient and calorie-dense food.
The nurse is caring for a client newly diagnosed with multiple sclerosis. The client indicates that there is so much to understand at one time. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. Which nursing action is correct?
Tell the client that the covering is called myelin and that you can discuss at the next meeting
The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care?
The client who played soccer in college
The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first?
The client with a basilar fracture
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?
The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.
A client presents to the walk-in clinic complaining of a migraine. The client is prescribed a neuronal stabilizer. What should the nurse suggest to the client?
Use caution while driving or performing hazardous activities.
A nursing instructor is teaching the senior nursing class about clients with neurologic disorder. The instructor tells the students that these clients are at risk of disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. What nursing intervention helps prevent plantar flexion?
Use of a footboard
Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.
cloudy cerebral spinal fluid, purpura of hands and feet
Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply.
elevated systolic blood pressure, wide pulse pressure
Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field?
ensure a clutter-free walkway
The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply.
monitor vital signs, intake and output, coughing and deep breathing, neurovascular assessment of the lower extremity, dressing assessment
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
turn client to side-lying position
The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/or leaking of cerebral spinal fluid?
Halo sign
A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct?
Have the client close his eyes and stand erect.
What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurologic deficit?
Help the client to the bathroom at a particular time each day.
A client is brought to the emergency department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other conditions are considered neurologic deficits? Select all that apply.
Impaired speech, abnormal bladder elimination, paralysis
The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority?
Include client in planning of care and setting of goals
The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?
Herniation occurs through the foramen magnum.
A video fluoroscopy has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client?
Impaired Swallowing
The nurse is employed in a neurologist's office, performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?
Cranial nerve VIII
The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care?
"Clients and families are the focus of hospice care."
The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?" The nurse is most helpful to say which of the following?
"Grief is a normal process. Let's discuss offering support throughout the process."
A client is prescribed sumatriptan (Imitrex) for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
"I use this to prevent migraines."
A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?
"My children are at greater risk to develop this disease."
The home care nurse is evaluating a post-cerebrovascular accident (CVA) client 1 week after returning to the home from a rehabilitation setting. Which of the following statements, made by the client, most concerns the nurse?
"My spouse goes to work in the morning and leaves my lunch at my bed stand."
A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement?
"TIA is a warning sign. Let's talk about lowering your risks."
The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct?
"The client may be experiencing a change in affect due to the brain injury."
The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used?
A cervical collar
A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes?
A unit of fresh frozen plasma is infusing.
The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?
Allergic reaction to the imaging material
A female client undergoes a scheduled electroencephalogram (EEG). Which of the following postprocedure activities should the nurse carry out for the client?
Allow the client to rest and shampoo the client's hair.
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?
An absence seizure
The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated?
Antihistamine
While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind his right eye, which is red and tearing. What type of headache would you suspect this client of having?
Cluster
The nurse is caring for a post-lumbar puncture client experiencing an intense headache. The physician is notified and arriving to assess the client. If the physician chooses aggressive treatment, which nursing action is anticipated?
Drawing venous blood to perform a blood patch
An elderly client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client?
Drooling from side of mouth
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?
Drooping eyelids
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?
Edema to the head with bruising of the mastoid process
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
Elevate the head of the bed.
A client, who was adopted at birth, recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears?
Encourage client to verbalize fears.
The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?
Epidural hematoma
You are caring for a client who has had intracranial surgery and is being discharged home. What instructions would you give the client besides instructions on the medication?
Expect sensory changes, such as hearing a clicking sound, around the bone flap.
The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client?
Explaining hospice care and services
A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client?
Hopelessness
A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client?
Identify and avoid factors that precipitate or intensify an attack.
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Left-sided cerebrovascular accident (CV A)
The nurse is caring for a client in the neurologic intensive care unit. The nurse is noting from the assessment findings that the client is lacking a connection because motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit?
Medulla oblongata
A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?
Migraines often coincide with menstrual cycle.
Which of the following assessment tools should the nurse use to perform a neurologic assessment?
Mini-Mental Status Examination
The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which nursing assessment is primary during this time of medication change?
Monitor vital sign fluctuation.
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?
Monitoring is needed as rapid neurologic deterioration may occur.
The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
Moving the head and chin toward the chest
A client is receiving baclofen (Lioresal) for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?
Muscle spasms
A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client?
Nausea
You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
Neurologic examination
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?
Neurovascular system
The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response?
Observing the client's response to painful stimulus
A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?
Occipital
When a nurse is caring for a client diagnosed with neurologic deficit who has begun responding to those around him, what therapy should the nurse suggest to help strengthen muscles that are under voluntary control?
Occupational therapy
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
Paresthesia
In which of the following disease processes is the nurse most likely to care for a client in the chronic phase of a neurologic disease?
Parkinson's disease
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken?
Perform a vision field assessment.
The nurse is providing care to a client with neurologic problems and notices that the client is experiencing a penile erection. Which nursing reaction is correct?
Perform duties professionally and explain that spontaneous erections are unpredictable
When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?
Perform stretching exercises and frequent position change.
The nurse is assessing a client's ability to detect sensation in the upper extremity. Which nursing actions would be appropriate? Select all that apply.
Place a warm cotton ball on the arm, a gentle pinch using fingers, drag the alcohol pad over the skin, touch the client with the pads of the finger
A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?
Position the client flat for at least 3 hours.
The nurse caring for a client in the chronic phase of a neurologic deficit knows that nursing management focus on what?
Preventing physical and psychological complications
Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident?
Prevention of joint contractures
A client you are caring for experiences a seizure. What would be a priority nursing action?
Protect the client from injury.
The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
Pulse and blood pressure
You are caring for an 82-year-old client who needs bladder training. You know that bladder training is difficult for older adult clients with neurologic deficit because of what?
Relaxation of the internal bladder sphincter
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches?
Relaxes muscles
The nurse is caring for a client following intracranial surgery. In the plan of care, the nurse states to remove antiembolism stockings. What would the nurse do to accurately complete this intervention?
Remove the antiembolism stockings briefly every 8 hours.
A client with a neurologic deficit has been admitted to your unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately?
Report the change to the physician.
The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord?
Second lumbar vertebrae
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
Seizure was 1 minute in duration including tonic-clonic activity.
Which nursing technique best allows the client with slight expressive aphasia to communicate his feelings about using adaptive equipment in public?
Sit beside client and patiently assist in interpreting communication.
The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline (Eldepryl) with carbidopa-levodopa (Sinemet) to the medication regime should result in which purpose?
Slows the progression of the disease
The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of conscious should the nurse document?
Somnolent
The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness?
Somnolent
A home health nurse is assisting the wheelchair-dependent, post-cerebrovascular accident client in transition from the rehabilitative center to home. Which of the following concerns would the nurse address first when assessing the client's home?
Steps to the front door
The nurse is caring for clients on a neurologic floor. Which client goal is most appropriate for the acute phase of a neurologic injury?
The client's vital signs will stabilize returning to baseline.
The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders?
The first thoracic vertebrae
The client is waiting in a triage area to learn the medical status of his family following a motor vehicle accident. The client is pacing, taking deep breaths, and wringing the hands. Considering the effects in the body systems, what effects does the nurse anticipate in the liver?
The liver will convert glycogen to glucose for immediate use.
The nurse is caring for a client in the emergency department with diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. For which action, made by the nurse aide, would the nurse provide further instruction?
The nurse aide moved the client's head to clean behind the ears.
The nurse is working in an outpatient studies unit administering neurologic tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. The nurse is most correct to state which?
The paste is removed with standard shampoo.
The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm?
The stimulation can increase intracranial pressure (ICP) or trigger a seizure.
The nurse is talking with a newly paralyzed client and his wife. The wife is trying to raise the client's spirits and begins talking about the possibility of them having a baby. When the wife is alone, which instruction in essential?
There is a reduced ability for your husband to be able to father children.
Which of the following goals is the priority in the care planning of a client with cerebrovascular accident (CVA) who is being transferred to a rehabilitation unit?
To prevent contractures and joint deformities
The client with hemiplegia is at risk for impaired walking. Which nursing intervention would best assist this client in preventing complications associated with lower extremity impairment?
Use of high-top tennis shoes throughout the day
Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy?
Use ophthalmic lubricant and protect the eye.
The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client?
Vector bites
The nurse is assisting a client, with a right-sided brain infarction, to transfer from the wheelchair to the bed. Which is the best placement of the wheelchair to facilitate this transfer?
Wheelchair placed on the right side of the bed facing the foot
The nurse is instructing the client on how to perform Credé's maneuver. In which situation is this maneuver helpful?
When a client is attempting to empty the bladder
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data?
When, if any, was your last narcotic use?
The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply.
anticonvulsants, analgesics, antidepressants
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.
unequal pupils, pinpoint pupils, absence of pupillary response
