NCLEX Neuro

A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. the nurse should avoid which action that could trigger an episode of this complication?

Allowing the clients bladder to become distended. RATIONALE:Autonomic dysreflexia is triggered most frequently by a distended bladder. To prevent this, straight catheterization is done every 4 to 6 hours, and indwelling urinary catheters are checked frequently to prevent kinks in the tubing. constipation and fecal impaction are other causes, so maintaining bowel regularity is important. other causes include stimulation of the skin from tactile, thermal, or painful stimuli.the nurse administer care to minimize risk in these areas.

the nurse is preparing to care for a client with a diagnosis of brain attack stroke. the nurse notes in the client record that the client has anosognosia. the nurse plans care, knowing which is a characteristic of anosognosia?

the client neglects the affected side RATIONALE:In anosognosia the client neglects the affected side of the body. the client may neglect the affected side often created a safety hazard as a result of potential injuries. or state that the involved arm or leg belongs to someone else.

the nurse is told in report that a client has a positive chvostek's sign. what other data Should the nurse expect to find on data collection?

tetany, diarrhea, possible seizure activity, positive Trousseau's sign. RATIONALE:A positive chvostek's sign which is indicative of hypocalcemia. other signs and symptoms include tachycardia, hypotension, paresthesia, twitching, cramps, tetany, seizures, positive Trousseau's sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval.

The nurse is caring for the client with a head injury secondary to a motor vehicle crash. The nurse observes the client status regularly, monitoring closely for what changes in vital signs that could indicate increased intracranial pressure?

Decreasing pulse, decreasing respirations, increasing BP RATIONALE:A change in vital signs may be a late indication of ICP. Trends include increasing BP and decreasing pulse and respiratory rate. Irregularities of respiratory rhythm may also arise.

The nurse is preparing for the admission of a client with with a suspected diagnosis of Gillian-Barre syndrome. what s/s is considered a primary symptom of this syndrome?

development of muscle weakness RATIONALE:A Hallmark symptom of GB syndrome is muscle weakness that develops rapidly.

The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that which is an early sign of rupture?

A decline in the LOC RATIONALE:Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure is a change in the LOC because compression of the reticular formation in the brain. this change in LOC can be as subtle as drowsiness, or restlessness. because centers that control blood pressure are located lower in the brain stem than those that control consciousness. motor weakness and widened pulse are later signs of ICP and has led to neurological damage.

what symptoms would validate the diagnosis of a cluster headache?

A runny nose, burning sensation in the eye, tearing on the affected eye. RATIONALE:The pain of a cluster headache peaks in about 5 minutes and may last for an hour. someone with a cluster headache may experience a pain free period of variable length. A burning sensation in the eye, tearing in the affected eye, and runny nose are common. sensitivity to light and sound occurs in migraine headaches.

A client with MG become increasingly weaker. the PHCP injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if the client is in cholinergic crisis?

A temporary worsening of the condition. RATIONALE: Edrophonium is a short acting acetylcholinesterase inhibitor used to diagnose MG or differentiate between myasthenic and cholinergic crisis. An Edrophonium injection makes the client in cholinergic crisis temporary worse, known as a negative Edrophonium test. An improvement of the condition indicates myasthenia crisis.

The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. what sign is indicative of this complication of a spinal cord injury?

Areflexia below the level of injury RATIONALE: Spinal shock represents a temporary but profound disruption of spinal cord function, which occurs immediately after injury and is clinically evident within 30to60minutes. it is a state of areflexia characterized by the loss of all neurological function below the level of injury. flaccid paralysis Bradycardia and hypotension occur. The body is unable to use either shivering or perspiring as a means of controlling body temperature.

the nurse is caring for a client with the diagnosis of myasthenia gravis. which primary health care providers prescription should the nurse question?

administer the prescribed anticholinesterase medication 30minutes after meals RATIONALE: corticosteroids are administered concurrently with the anticholinesterase drug daily in the morning is an expected schedule. because a large number of patients with MG have hyperplasia of the thymus gland, Thymectomy is performed early after the initial diagnosis. Plasmepheresis is an adjunctive therapy based on the autoimmune theory of MG anticholinesterase drugs are ordered 30minutes before meals to improve muscle strength.

A client with PD is developing dementia what action should the nurse plan to assist the client in maintaining self care abilities?

breakdown activities into small steps RATIONALE: it is often necessary to breakdown activities of ADL such as dressing into small steps and explain what is happening at each step in very specific and simple terms. large groups and complex activities should be avoided when clients have Parkinson's disease and dementia because they are likely to cause the individual to become agitated or have a catastrophic reaction become angry and display aggressive behavior routine is very important and it is necessary to introduce changes very slowly so the day and time bathing should remain constant. music is a positive influence including improved capacity to communicate reminiscing and and recall memories.

the nurse is collecting data on a client diagnosed with PD. what finding indicates a serious complication of this disorder?

congested cough and coarse rhonchi heard during auscultation. RATIONALE:clients with PD are at risk for aspiration. A congested cough and coarse rhonchi may be present after a client aspirate. Although constipation is a problem for clients with PD, the concern is greater if the client has not had a BM by the 3rd day. resting and pill rolling tremors and a shuffling, propulsive gait characteristics findings in PD

the nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. this conclusion is based on what findings?

drainage from the ear, bruising around the eyes, pink tinged drainage from the nose. RATIONALE: Drainage from the ear or nose (clear or pink tinged) is an indicator of the presence of CSF, which could be leaking as a result of the skull fracture. brushing around the eyes (raccoon sign) is also an indicator of basilar skull fractures.

A client has just undergone lumbar puncture. The nurse assists the client into what optimal position?

flat, turning side to side as needed. RATIONALE:keep client flat in bed to reduce headache for 1 hour or longer after procedure. it is important that the head of the bed remain flat to prevent CSF leakage and to prevent postprocedure headache.

A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which S/S?

tachycardia, photophobia, red, macular rash, and positive kernig sign. RATIONALE: Meningitis is an infection or inflammation of the membranes covering the brain and spinal cord. s/s can include a positive kernig sign, tachycardia,(heart rate greater than 100bpm), a red macular type rash and photophobia. other s/s include severe headache, stiffness of the neck, irratibility, malaise, and restlessness.

A client with a stroke is experiencing residual dysphagia. The nurse Should remove which food from her tray.

peas RATIONALE:In general, flavorful, very warm, or well chilled foods with texture stimulate the swallowing reflex. most pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw vegetables chunky vegetables such as diced beets and stringy vegetables such as spinach corn and peas are commonly excluded from the diet of a client with poor swallowing reflex.

A client recovering from a craniotomy complains of a runny nose. Based on the interpretation of the clients complaint, what action should the nurse take?

notify the registered nurse. RATIONALE:If the client has sustained a craniocerebral injury or is recovering from a craniotomy, careful observation of any drainages from the eyes,ears,nose, or traumatic area is critical.cerebrospinal fluid is colorless and generally nonpurulent,and it's presence is indicative of a serious breach of cranial integrity. the nurse would check the drainage for the presence of glucose, which would be indicative of the presence of CSF and would report the presence of any suspicious drainage to the RN who would then contact the PHCP.

The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. what assessment will provide the nurse with the best information about recovery from the spinal shock?

reflexes RATIONALE: Areflexia characterizes spinal shock; therefore, reflexes should provide the best information. vital sign changes are not consistently affected by spinal shock

A client who suffered a cervical spine injury had crutchfield tongs applied in the emergency room department. The nurse Should avoid which action in the care of the client?

removing the weights when repositioning the client. RATIONALE: crutchfield tongs are a method of skeletal traction used with cervical spine injury. All of the principles of assessment and care that apply to the client in traction apply to this client. The nurse Should not remove the weights to administer care; removing the weights will disrupt the traction applied. The nurse should ensure that weights hang freely and that the amount of weight matches the current prescription. The nurse should inspect the integrity and position of the ropes and pulleys. the client is placed on Stryker frame roto rest bed while the crutchfield tongs are in use.

A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). what finding is indicative of this complication?

the client complains of a headache,and the blood pressure is elevated. RATIONALE: autonomic dysreflexia also known as hyperreflexia is a life threatening syndrome. it is a cluster of clinical symptoms that result when multiple spinal cord autonomic responses discharge simultaneously. exaggerated autonomic nervous system reaction to stimuli result in sudden hypertensive episodes with severe headache. The client may sweat profusely above level of the cord lesion and complain of a stuffy nose. the knee jerk response is not affected. pupils may be dilated. Although a distended bladder is often the precipitating event,it is not indicative of dysreflexia and not all clients with bladder distention exhibit dysreflexia

A client with tetraplegia complains bitterly about the nurse slow response to the call light and rigidity of the therapy schedule. what interpretation of this behavior should serve as a basis for planning nursing care?

the client is reacting to loss of control. RATIONALE: clients who feel a sense of control over their situation will adapt to their limitations more readily than those who think that they have lost control. both of the client complaints indicate a need for greater control clients should be offered an opportunity for input into scheduling and planning for staff response to their needs.

A client is recovering at home after suffering a stroke 2weeks ago. A home caregiver tells the home health nurse that the client has some difficulty swallowing food and fluids. what nursing action would be appropriate?

observe the client feeding him/herself. RATIONALE:it is not uncommon for a client to have difficulty swallowing after having a stroke. often the client has hemiplegia. The client arm may be paralyzed and the client has to learn to use an opposite arm to feed himself using a different arm may require rehab and retraining. also a client may have partial paralysis of the mouth tongue or esophagus. To best assist the client the nurse should first assess the situation vby watching the client feed himself. perhaps the problem lies in the feeding technique the type of feeding tool used the types of food being served, or a combination of problems. having someone else feed the client maybe necessary if the client is determined to be unable to feed himself but this action does not promote independence in the client. A feeding syringe is not recommended for feeding most clients.

A client complains of pain in the lower back and pain spasms in the hamstrings when the nurse attempts to extend the clients leg. how should the nurse record this finding on the client medical record?

positive kernig sign. RATIONALE: both kernig and brudzinski signs are suggestive of meningeal irratation. which occurs in Meningitis. A positive kernig sign is the inability to extend the leg from a 90 degree flexion at the hip. Attempts to extend the leg cause pain and spasms in the hamstring muscles. With positive brudzinski sign passive flexion of the head and neck causes flexion of the thighs and legs.

the nurse is collecting neurological data on a poststroke adult client. What technique should the nurse perform to adequately check proprioception?

hold the sides of the client great toe and while moving it ask what position it is in. RATIONALE: proprioception is tested by holding the sides of the clients great toe and, while moving it, asking the client what position it is in.

The nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 (thoracic 3) level what clinical symptoms will be observed?

hypotension and Bradycardia. RATIONALE: spinal cord transection at the T5 level or above may lead to neurogenic shock. This injury results in massive vasodilation without compensation because of the loss of sympathetic nervous system vasocontrictor tone. As a result, hypotension and Bradycardia will be manifested

the nurse is caring for a client with a diagnosis of stroke with anosognosia. To meet the needs of the client with this deficit, what action does the nurse plan?

increase the clients awareness of the affected side RATIONALE:in anosognosia the client neglects the affected side of the body. The nurse should plan care activities that encourage the client to look at the affected arm or leg and that will increase the client awareness of the affected side.

The nurse is assisting in the care of a client who is being evaluated for possible MG. the PHCP gives a test dose of edrophonium. the nurse recalls that the client should have what reaction it the client has the disease?

An increase in muscle strength within 1-3min RATIONALE: Edrophonium is a short acting acetylcholinesterase inhibitor used to diagnose MG. An increase in muscle strength should be seen in 1-3min following the test dose of the client does have the disease. If no response occurs, another dose is given over the next 2minutes, and muscle strength again is tested. If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by MG. clients who receive injections of this medication commonly demonstrate a drop in blood pressure, feel faint and dizzy and are flushed.

The nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. what statement by the client indicates understanding of the discharge instructions?

I need to call the doctor if I develop frequent swallowing or postnasal drip. RATIONALE: The client should report frequent swallowing or postnasal drip after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The surgeon removes the nasal packing usually after 24hrs. The client should deep breath, but coughing is contraindicated because it could cause ICP. the client Should also report a severe headache because it could indicate ICP.

the nurse is preparing a plan of care for a client with a stroke who has global aphasia. the nurse incorporates communication strategies in the plan of care, knowing that the client speech should fit what characterization?

associated with poor comprehension RATIONALE:global aphasia is a condition in which a person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words by another, and the speech is characterized by literal paraphasia with intact comprehension. the client with wernicks aphasia may exhibit a rambling type of speech.

A client with suspected Gillian Barre syndrome has a lumbar puncture performed. the CSF protein is 750mg/dl. The nurse analyzes these results as what?

higher than normal, supporting the diagnosis of Gillian-Barre RATIONALE:7-10 days following the onset of symptoms of GB, the spinal fluid protein levels become extremely high. Normal CSF protein is 15-45mg/do. A value of 750mg/do is higher than normal, supporting the diagnosis of GBS.

A client with bells palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of what cranial nerve (CN)?

CN VII RATIONALE:Bells palsy is a common problem involving cn vii.in addition to the symptoms identified in the question, the client may exhibit loss of the nasolabial fold, an inability to blink automatically or to swallow secretions, and possible loss of taste on the anterior 2 thirds of tongue.other conditions that can affect cn VII function include fracture of the temporal bone and parotid lacerations or contusions.

the nurse is caring for a client with a spinal cord injury. high top sneakers on the client feet will prevent the occurrence of what?

foot drops RATIONALE: The most effective way to prevent foot drops is to use posterior splints or hightop sneakers. A foot board prevents plantar flexion but also places the client at greater risk for developing pressure ulcers of the feet. pneumatic boots prevent DVT but Not foot drop.

a female client with MG comes into the PHCP office for a visit. the client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. what is the appropriate nursing response?

have you thought about sharing your feelings with your husband? RATIONALE: Encouraging the client to share feelings with her husband directly addresses the subject of the question.

the nurse is collecting admission data on a client with PD. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which in the clients record?

positive Romberg test. RATIONALE: Rombergs test checks for cerebellar functioning related to balance. the client stands with the feet together and arms at the side and then closes the eyes. slight swaying is normal,but loss of balance indicates a problem and a positive Rombergs test. Trousseau's sign indicates a calcium imbalance.

the nurse Is caring for a client with a head injury and is monitoring the client for signs of ICP. what sign, if noted in the client, should the nurse report immediately?

the client vomit RATIONALE: the client with a closed head injury is at risk of developing ICP. This is evidenced by symptoms such as headache, dizziness, confusion, weakness, and vomiting if client complains of dizziness when getting out of bed for the 1st time, or complain of pain at the site of injury, or complain of feeling tired these are all EXPECTED occurences

a client is suspected of having a diagnosis of Gillian-Barre syndrome what findings would support a diagnosis of GBS?

visual and hearing disturbances ascending symmetrical muscle weakness. RATIONALE:GBS may affect cranial nerves resulting in visual and hearing disturbances. IT is characterized by symmetrical muscle weakness that typically begins in the lower extremities and ascends to the trunk and upper extremities.Approximately 95% of patients with GBS have a nearly complete recovery. Despite all the motor and sensory changes, level of consciousness and intellectual functioning remain unchanged

A client sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8hour shift was 3300ml, and 2800ml the shift before that. the findings have been reported to the PHCP provider, and the nurse anticipates a prescription for what medication?

Desmopressin. RATIONALE:A complication of closed head injury is Diabetes insipidus. this may occur if the injury affects the hypothalamus, antidiuretic hormone storage vesicles, or the posterior pituitary gland. urine output that exceeds 9L/day generally requires treatment with desmopressin,an antidiuretic.

The nurse is reinforcing instructions to the client who has just been fitted for a Halo vest. what statement by the client indicates the need for further teaching?

I will avoid driving at night because the vest limits the ability to turn the head. RATIONALE: A client wearing a Halo vest should not drive at all because the device impairs head movement and the range of vision. the inability to turn the head without the torso would make driving contraindicated. The Halo device does alter balance and can pose increased risk of falling. the client should clean the skin under the vest daily to protect the skin from ulcerations and should use powder or lotions sparingly or not at all. the client should have food cut into small pieces to facilitate chewing and use straws for drinking because the head immboliziation makes eating and drinking harder.

a Halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching?

I will bend at the waist, keeping the Halo vest straight to pick up items. RATIONALE:The client with a Halo vest should avoid bending at the waist because the Halo vest is heavy and the clients trunk is limited in flexibility. it is helpful for the client to scan the environment visually because the clients peripheral vision is diminished from keeping the neck in a stationary position. use of a walker and rubber soled shoes may help prevent falls and injury so these items are also helpful.

A client has just undergone computed tomography (CT) scanning with a contrast medium. The nurse determines that the client understand postprocedure when the client makes which statement?

I will drink extra fluids for the rest of the day. RATIONALE: After a CT scanning, the client may resume all usual activities. The client Should be encouraged to take in extra fluid to replace those lost with diuresis from contrast dye.

A client with Parkinson's disease freezes while ambulating, increasing the risk for falls. wat suggestion should the nurse include in the clients plan of care to allieviate this problem?

consciously think about walking over imaginery lines on the floor. RATIONALE:(freezing or no movement). having these individuals imagine lines on the floor to step over can keep them moving forward. although standing erect and using a cane help prevent falls, these measures will not help a person with akinseia move forward. clients with PD should walk with a wide gait, not with the feet close together. A wheelchair should be used only when the client can no longer ambulate with assistive devices such as canes or walkers.

the nurse is caring for a client who sustained a spinal cord injury. while administering morning care, the client developed s/s of autonomic dysreflexia. what is the initial nursing action?

elevate the head of the bed RATIONALE: autonomic dysreflexia is a serious complication that can occur in the spinal cord of the injured client. once the syndrome is identified, the nurse elevated the head of the bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client blood pressure, but the initial action is to elevate the HOB the client should NOT be placed in probe position.

A client with GBS has been asking many questions about the condition, and the nursing staff feels that the client is very discouraged about her condition it is important for the nurse to include which information in discussions with the client?

generally, a vast number of people recover from this condition. RATIONALE: the vast majority of clients with GBS recover from paralysis because it affects peripheral nerves that have the capacity to remyelinate. Maximum paralysis progresses distally to proximally. Rehabilitation can take from 6months to 2years.

the nurse is assisting in admitting a client who experienced seizure activity in the emergency department. the nurse avoids which action when managing this client environment?

keeping the bed position raised to the nurses waist level. RATIONALE:seizure precautions may very somewhat from agency to agency, but generally have some commonalities. Usually an airway, oxygen, and suctioning equipment are kept available at the bedside. the side rails of the bed are padded, and the bed is kept in the lowest position. The client has an IV access in place to have a readily accessible route if IV anticonvulsant medications must be administered.

the nurse is caring for a client with a diagnosis of right (non dominant) hemispheric brain attack (stroke) the nurse notes that the client is alert and oriented to time and place.based on these findings,the nurse makes which determination?

the client may have perceptual and spatial disabilities RATIONALE:the client with a nondominant hemispheric stroke may be alert to time and place. these signs of apparent wellness often result in interpretation that the client is less disabled than in this case. however, impulsive actions and confusion in carrying out activities may be very much a problem for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory perceptual and visuospatial processing and awareness of body space. the left hemisphere is dominant for language abilities

The nurse is planning care for a client with bells palsy. what measure should be included in the plan?

instill artificial tears and wear a patch over the affected eye at night. RATIONALE:instilling artificial tears and patching the affected eye at night protects the eye from corneal abrasions.warm packs will alleviate discomfort. wearing dark glasses is recommended, as is gentle massage of the affected side.

The nurse developes a plan of care for a client following a lumbar puncture. what interventions should be included in the plan?

monitor the client ability to void. maintain the client in a flat position. monitor the client ability to move the extremities. inspect the puncture site for swelling, redness, and drainage. RATIONALE: following a lumbar puncture, the client remains flat in bed for 6-24hrs depending on the PHCP prescription. A liberal fluid intake ( not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure, unless contraindicated by the client condition. The nurse checks the puncture site for redness, and drainage and monitors the client ability to void and move the extremities.

the nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma which nursing intervention does the nurse document in the plan as a priority for this client?

monitor urine output. RATIONALE: The most common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from deficiency in Antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client urine output to determine whether this complication is occurring monitoring temp, B/P and apical pulse are also needed but urine output is PRIORITY!!

The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having episodes of crying,and is sleeping excessively which method is the best way for the nurse to explore issues with the client regarding these behaviors?

have the client express the feelings in writing. RATIONALE:speaking can exacerbate the pain that occurs with trigeminal neuralgia. Having the client record feelings in writing will help the nurse gain an understanding of the clients concerns without increasing the client pain. the nurse Should explore the client concerns and offer support.

the nurse is assisting in checking for Tinel's sign in a client suspected of having carpal tunnel syndrome (CTS). what technique should the nurse expect to be used to elicit this sign?

percuss the medial nerve at the wrist as it enters the carpal tunnel, and monitor for tingling sensations. RATIONALE:The presence of Tinel sign is determined by percussing the medial nerve at the wrist as it enters the carpal tunnel. A tingling sensation over the distribution of the nerve occurs in CTS. the presence of phalens sign is determined by asking the client to flex the wrist at a 90 degree angle for 1 minute. Numbness and tingling over the distribution of the median nerve, the palmar surface of the thumb, and the index and middle fingers suggest CTS. phalens sign is also an indication of CTS.