Neuro

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma? A. 6 B. 9 C. 12 D. 15

A. 6 A score of 8 or below indicates coma.

Which actions should the nurse take for a client who underwent cerebral angiography? Select all that apply. A. Wipe off the gel applied before the test B. Maintain pressure dressing for two hours C. Remove the electrodes gently and thoroughly D. Obtain vital signs and complete neurologic checks E. Check dressing for bleeding and swelling around the site

B. Maintain pressure dressing for two hours D. Obtain vital signs and complete neurologic checks E. Check dressing for bleeding and swelling around the site

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? 1.Reduce environmental noise. 2.Allow visitors as desired by the client and family. 3.Awaken the client every 2 to 3 hours to monitor mental status. 4.Cluster nursing activities to reduce the number of interruptions.

1.Reduce environmental noise.

After a cerebrovascular accident (also known as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected? A. Frontal B. Parietal C. Occipital D. Temporal

B. Parietal

Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why the client cries easily and without provocation. How does the nurse explain the client's behavior? A. Is making an attempt to get attention B. Has selective memory from the past, especially the sad events C. Has little control over this behavior D. Feels guilty about the demands being made on the family

C. Has little control over this behavior Emotional instability usually is caused by lesions affecting the thalamic area (the part of the neural system most responsible for emotions).

A nurse assesses a client and observes the condition depicted in the image. How will the nurse chart this finding? A. Otorrhea present B. Halo sign present C. Rhinorrhea present D. Battle's sign present

D. Battle's sign present The condition depicted in the figure is Battle's sign, which is characterized by postauricular ecchymosis.

A client is admitted to the emergency department with a head injury. A computed tomography (CT) scan shows a subdural hematoma. How should the nurse interpret this finding of a subdural hematoma? A. Blood within the brain tissue B. Blood in the subarachnoid space C. Blood between the dura and the skull D. Blood between the dura mater and the arachnoid layer

D. Blood between the dura mater and the arachnoid layer A subdural hematoma refers to blood between the dura mater and the arachnoid layer of the meninges. Blood within the brain tissue is an intracerebral hematoma. Blood in the subarachnoid space is below the arachnoid and is called a subarachnoid hematoma. An epidural hematoma refers to blood between the dura and the skull.

A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question? A. Continue anticonvulsants B. Teach isometric exercises C. Continue osmotic diuretics D. Keep head of bed at 30 degrees

B. Teach isometric exercises The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure.

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 1.Altered breathing pattern 2.Increased likelihood of injury 3.Ineffective oxygen consumption 4.Increased susceptibility to aspiration

1.Altered breathing pattern

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex/triad. The nurse determines that the presence of this reflex is obtained by assessing which item? 1.Blood pressure 2.Motor response 3.Pupillary response 4.Level of consciousness

1.Blood pressure Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1.Confusion 2.Bradycardia 3.Sluggish pupils 4.A widened pulse pressure

1.Confusion Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Note the strategic word, early. Recalling that the earliest indicator of increased ICP is changes in level of consciousness will direct you to the correct option.

The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. 1.Eye opening 2.Reflex response 3.Best verbal response 4.Best motor response 5.Pupil size and reaction

1.Eye opening 3.Best verbal response 4.Best motor response

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Flat, with head turned to the side 4.Head of bed elevated 30 to 45 degrees 5.Head of bed elevated with the neck extended

1.Head midline 2.Neck in neutral position 4.Head of bed elevated 30 to 45 degrees

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least once a week

1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 4.Turning and repositioning the client at least every 2 hours Remember that autonomic dysreflexia is caused by noxious stimuli to the bowel, bladder, or skin. With this in mind, you can eliminate easily each of the incorrect options.

The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client? 1.Shift weight every 2 hours while in a wheelchair. 2.Change bed sheets every other week to maintain cleanliness. 3.Place a pillow on the seat of the wheelchair to provide extra comfort. 4.Use a mirror to inspect for redness and skin breakdown twice a week.

1.Shift weight every 2 hours while in a wheelchair.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1.Sounds will not be heard clearly unless they are loud. 2.Obtain assistance with ambulation if the client is lightheaded. 3.Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. 4.Use a check-off system for administering anticonvulsant medications to avoid missing doses.

1.Sounds will not be heard clearly unless they are loud. The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client.

The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply. 1.Speaking to the client at a slower rate 2.Allowing plenty of time for the client to respond 3.Completing the sentences that the client cannot finish 4.Looking directly at the client during attempts at speech 5.Shouting words if it seems as though the client has difficulty understanding

1.Speaking to the client at a slower rate 2.Allowing plenty of time for the client to respond 4.Looking directly at the client during attempts at speech

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1.The client is aphasic. 2.The client has weakness on the right side of the body. 3.The client has complete bilateral paralysis of the arms and legs. 4.The client has weakness on the right side of the face and tongue. 5.The client has lost the ability to move the right arm but is able to walk independently. 6.The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

1.The client is aphasic. 2.The client has weakness on the right side of the body. 4.The client has weakness on the right side of the face and tongue.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? 1.The intracranial pressure reading is normal. 2.The intracranial pressure reading is elevated. 3.The intracranial pressure reading is borderline. 4.An intracranial pressure reading of 8 mm Hg is low.

1.The intracranial pressure reading is normal.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1.The left side of the body 2.The right side of the body 3.Both sides of the body equally 4.Cranial nerves only, such as speech and pupillary response

1.The left side of the body

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. 1.Thicken liquids. 2.Assist the client with eating. 3.Assess for the presence of a swallow reflex. 4.Place the food on the affected side of the mouth. 5.Provide ample time for the client to chew and swallow.

1.Thicken liquids. 2.Assist the client with eating. 3.Assess for the presence of a swallow reflex. 5.Provide ample time for the client to chew and swallow.

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply. 1.Using a RotoRest bed 2.Ensuring that weights hang freely 3.Removing the weights to reposition the client 4.Assessing the integrity of the weights and pulleys 5.Comparing the amount of prescribed traction with the amount in use

1.Using a RotoRest bed 2.Ensuring that weights hang freely 4.Assessing the integrity of the weights and pulleys 5.Comparing the amount of prescribed traction with the amount in use

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? 1."I will use a straw for drinking." 2."I will drive only during the daytime." 3."I will be careful because the device alters balance." 4."I will wash the skin daily under the lamb's wool liner of the vest."

2."I will drive only during the daytime."

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? 1."When did the injury occur?" 2."Was the client awake and talking right after the injury?" 3."What medications has the client received since the fall?" 4."What was the client's level of consciousness before the injury?"

2."Was the client awake and talking right after the injury?" Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1.Clustering nursing activities 2.Hyperoxygenating before suctioning 3.Maintaining 20 degree flexion of the knees 4.Maintaining the head and neck in midline position 5.Maintaining the head of the bed (HOB) at 30 degrees elevation

2.Hyperoxygenating before suctioning 4.Maintaining the head and neck in midline position 5.Maintaining the head of the bed (HOB) at 30 degrees elevation

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1.Bilateral loss of pain and temperature sensation 2.Ipsilateral paralysis and loss of touch and vibration 3.Contralateral paralysis and loss of touch, pressure, and vibration 4.Complete paraplegia or quadriplegia, depending on the level of injury

2.Ipsilateral paralysis and loss of touch and vibration

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1.Updating the home safety sheet 2.Leaving the client in an unchilled area of the room 3.Noting a bowel movement on the client progress note 4.Recording the amount of urine obtained with catheterization

2.Leaving the client in an unchilled area of the room Note the subject, preventing an episode of autonomic dysreflexia. This implies an action orientation on the part of the nurse. Each of the incorrect options contains an item related to documentation rather than an action to be taken by the nurse just before leaving.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1.Take the temperature. 2.Listen to breath sounds. 3.Observe for dyskinesias. 4.Assess extremity muscle strength.

2.Listen to breath sounds.

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that the family needs further teaching if they verbalize to call the health care provider (HCP) for which client sign or symptom? 1.Vomiting 2.Minor headache 3.Difficulty speaking 4.Difficulty awakening

2.Minor headache

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? 1.Tightened screws 2.Red skin areas under the jacket 3.Clean and dry lamb's wool jacket lining 4.Finger-width space between the jacket and the skin

2.Red skin areas under the jacket Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure could lead to altered skin integrity and needs to be relieved by loosening the jacket.

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? 1.Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear 2.Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear 3.Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally 4.Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

2.Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder

3.Flaccid paralysis Recall that spinal shock is characterized by the loss of movement of skeletal muscles, loss of bowel or bladder wall function, and depressed reflex action. Return of any of these indicates that spinal shock is beginning to resolve

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1.Head of bed flat, head and neck midline 2.Head of bed flat, head turned to the nonoperative side 3.Head of bed elevated 30 to 45 degrees, head and neck midline 4.Head of bed elevated 30 to 45 degrees, head turned to the operative side

3.Head of bed elevated 30 to 45 degrees, head and neck midline

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1.Notify the health care provider (HCP). 2.Loosen tight clothing on the client. 3.Place the client in a sitting position. 4.Check the urinary catheter tubing for kinks or obstruction.

3.Place the client in a sitting position.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? 1.Sudden loss of consciousness occurred. 2.Signs and symptoms occurred suddenly. 3.The client experienced paresthesias a few days before admission to the hospital. 4.The client complained of a severe headache, which was followed by sudden onset of paralysis.

3.The client experienced paresthesias a few days before admission to the hospital. Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on 1 side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures.

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? 1. A history of diarrhea 2. A flattened abdomen 3. Hyperactive bowel sounds 4. Hematest-positive nasogastric tube drainage

4. Hematest-positive nasogastric tube drainage Development of a stress ulcer also can occur after spinal cord injury and can be detected by Hematest-positive nasogastric tube aspirate or stool.

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? 1."Have you had any headaches in the past few days?" 2."Have you recently been having difficulty with seeing at nighttime?" 3."Have you had any sudden episodes of passing out in the past few days?" 4."Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

4."Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" Focus on the subject, the signs and symptoms of a thrombotic stroke. It is necessary to know that cerebral thrombosis does not occur suddenly, and in the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1."We need to discourage him from wearing eyeglasses." 2."We need to place objects in his impaired field of vision." 3."We need to approach him from the impaired field of vision." 4."We need to remind him to turn his head to scan the lost visual field."

4."We need to remind him to turn his head to scan the lost visual field."

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1.Return of spinal shock 2.Malignant hypertension 3.Impending brain attack (stroke) 4.Autonomic dysreflexia (hyperreflexia)

4.Autonomic dysreflexia (hyperreflexia)

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4.Exhaling during repositioning

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.

4.Fluid separates into concentric rings and tests positive for glucose.

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? 1.Prone 2.Supine 3.Semi Fowler's with the hip and the neck flexed 4.Head of the bed elevated 30 degrees with the head in midline position

4.Head of the bed elevated 30 degrees with the head in midline position Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? 1.Place an eye patch on the left eye. 2.Place personal articles on the client's right side. 3.Approach the client from the right field of vision. 4.Instruct the client to turn the head to scan the right visual field.

4.Instruct the client to turn the head to scan the right visual field.

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? 1.Had a very mild stroke 2.Most likely suffered a transient ischemic attack 3.May have difficulty with language abilities only 4.Is likely to have perceptual and spatial disabilities

4.Is likely to have perceptual and spatial disabilities The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities. Eliminate option 3 first because of the closed-ended word only. Regarding the remaining options, it is necessary to recall that perceptual and spatial disabilities occur in the client with a right hemispheric stroke.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? 1.Take and record vital signs every 4 to 8 hours. 2.Prophylactically hyperventilate during the first 24 hours. 3.Treat a central fever with the administration of antipyretic medications such as acetaminophen. 4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

A client who had a brain attack (cerebrovascular accident, CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding in the client's medical record? A. Anomia B. Apraxia C. Dysarthria D. Dysphagia

A. Anomia Clients with anomia cannot remember names of objects. Clients with apraxia cannot use objects properly or complete sequential movement. Clients with dysarthria know what they want to say but cannot speak clearly because there is motor impairment caused by a central or peripheral nervous system injury. Clients with dysphagia have difficulty swallowing; they do not have a speech problem.

A college athlete sustained a complete transection of the spinal cord while practicing on a trampoline. The healthcare provider explains that return of function to the lower extremities is not likely to occur. Two weeks later, the client verbalizes the need to get out of the hospital to practice for an upcoming tournament. Which is the nurse's most appropriate conclusion about the client's statement? A. Exhibiting denial B. Verbalizing a fantasy C. No longer able to adapt D. Motivated to recover mobility

A. Exhibiting denial

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

A. Leave the individual lying on the back with instructions not to move, and seek additional help. The individual should be moved only with a backboard to avoid additional spinal cord damage. Moving a person whose spinal cord has been injured may cause irreversible paralysis. A back injury precludes changing the person's position. A back injury is suspected; therefore the person should not be moved. A flat board is indicated; however, one rescuer should not move the person without help.

A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client? A. Maintain balance to improve stability B. Relieve pressure on weight-bearing joints C. Prevent further injury to weakened muscles D. Aid in controlling involuntary muscle movements

A. Maintain balance to improve stability Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability. Hemiparesis affects muscle strength on one side of the body; the joints are not directly affected.

A client who is diagnosed as having a herniated nucleus pulposus reports pain. What should the nurse most likely conclude is the cause of this client's pain? A. Inflammation of the lamina of the involved vertebra B. Shifting of two adjacent vertebral bodies out of alignment C. Compression of the spinal cord by the extruded nucleus pulposus D. Increased pressure of cerebrospinal fluid within the vertebral column

C. Compression of the spinal cord by the extruded nucleus pulposus Pain results because herniation of the nucleus pulposus into the spinal column irritates the spinal cord or the roots of spinal nerves.

Which clinical indicator does a nurse identify when assessing a client with hemiplegia? A. Paresis of both lower extremities B. Paralysis of one side of the body C. Paralysis of both lower extremities D. Paresis of upper and lower extremities

B. Paralysis of one side of the body Hemiplegia is paralysis of one side of the body. Paresis is a weakness or partial paralysis. Paraplegia is the paralysis of both lower extremities and the lower trunk. Paresis of upper and lower extremities is quadriparesis.

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours? A. Maintain comfort B. Prevent pressure ulcers C. Prevent flexion contractures of the extremities D. Improve venous circulation in the lower extremities

B. Prevent pressure ulcers

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? A. Hazy B. Yellow C. Brown D. Colorless

B. Yellow The yellow color of CSF can be attributed to the hemolysis of the red blood cells (RBC), which leads to increased production of bilirubin

A client who had a cerebrovascular accident (CVA, "brain attack") is starting to eat lunch. Which client behavior indicates to the nurse that the client may be experiencing left hemianopsia? A. Asks to have food moved to the left side of the tray B. Drops the coffee cup when trying to use the right hand C. Ignores the food on the left side of the tray when eating D. Reports not being able to use the right arm to help eat meals

C. Ignores the food on the left side of the tray when eating Clients with hemianopsia affecting the left field of vision cannot see whatever is in the left field of vision.

Which test is used to specifically detect intracranial aneurysms in clients? A. Diffusion imaging B. Magnetic resonance imaging C. Magnetic resonance angiography D. Magnetic resonance spectroscopy

C. Magnetic resonance angiography Magnetic resonance angiography is used to evaluate blood flow and blood vessel abnormalities, such as arterial blockage, intracranial aneurysms, and arteriovenous malformations.

The spouse of a client who had a cerebrovascular accident (also known as a "brain attack") seems unable to accept the concept that the client must be encouraged to participate in self-care. What is the best response by the nurse? A. Tell the spouse to let the client do things independently. B. Allow the spouse to assume total responsibility for the client's care. C. Explain that the nursing staff has full responsibility for the client's activities. D. Ask the spouse for assistance in planning those activities most helpful to the client.

D. Ask the spouse for assistance in planning those activities most helpful to the client. To foster communication and cooperation, family members should be involved in planning and implementing care.

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care? A. Spinal shock B. Brain herniation C. Hypovolemic shock D. Increased intracranial pressure

D. Increased intracranial pressure Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure. Spinal shock is manifested by a decreased systolic blood pressure with no pupillary changes. Brain herniation is manifested by dilated pupils and severe posturing. Hypovolemic shock is indicated by a decrease in systolic pressure and tachycardia, with no changes in pupillary reaction.

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision? A. Virus-induced iritis B. Intracranial pressure C. Closed-angle glaucoma D. Optic nerve inflammation

D. Optic nerve inflammation Optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission.

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response? A. Ventricular fibrillation B. Dysfunction of the vagus nerve C. Retention of sensation but paralysis of the lower extremities D. Respiratory paralysis and cessation of diaphragmatic contractions

D. Respiratory paralysis and cessation of diaphragmatic contractions The phrenic nerve innervates the diaphragm. Therefore a crushing spinal cord injury above the cervical plexuses, the level of phrenic nerve origin, results in respiratory paralysis. In a crushing spinal cord injury, both motor and sensory conduction are affected.

The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response? A. This is a way of getting attention that should be ignored. B. The client can remember only depressing events from the past. C. The client feels guilty about the demands being placed on the family. D. This behavior is a common response over which the client has very little control.

D. This behavior is a common response over which the client has very little control. If the client exhibits emotional instability, this usually is caused by lesions that affect the thalamic area in the part of the neural system most responsible for emotions.

The nurse is caring for a client who is admitted with a crushing injury to the spinal cord above the level of phrenic nerve origin. What should the nurse consider about this type of injury when planning care? a. Ventricular fibrillation b. Vagus nerve dysfunction c. Retention of sensation and paralysis of lower extremities d. Lack of diaphragmatic contractions and respiratory paralysis

d. Lack of diaphragmatic contractions and respiratory paralysis The phrenic nerves innervate the diaphragm; therefore, a crushing spinal cord injury above the level of phrenic origin will stop diaphragmatic contractions and result in respiratory paralysis.