Neuro ati

A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which of the following positions will be used during the procedure?

Side-lying with the legs pulled up and the head bent down onto the chesT

A nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin (Ditropan). The nurse evaluates the effectiveness of the medication by asking the client which of the following questions?

"Are you getting up at night to urinate?"

A client with Parkinson's disease quickly develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem?

"Consciously think about walking over imaginary lines on the floor."

A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse would provide reassurance to the client about the procedure?

"Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure."

A nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs more information if the client makes which of the following statements?

"Going to the beach will be a nice, relaxing form of activity."

A nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client states:

"Good oral hygiene is needed, including brushing and flossing."

A female client with myasthenia gravis comes to the health care provider's office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. The appropriate nursing response is:

"Have you thought about sharing your feelings with your husband?"

A nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client states:

"I can't swallow very well today."

A nurse is providing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. Which statement by the client indicates the client understands the discharge instructions?

"I need to call the doctor if I develop frequent swallowing or postnasal drip."

A nurse is providing instructions to the client who has just been fitted for a halo vest. Which statement by the client indicates the need for further instructions?

"I will avoid driving at night because the vest limits the ability to turn the head."

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

"I will bend at the waist, keeping the halo vest straight to pick up items."

A nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further instruction?

"I will not hear sounds clearly unless they are loud."

A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which of the following would be an appropriate response by the nurse?

"I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father."

A nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complication of hypothermia blanket use?

Skin breakdown

Which data collection finding supports the possible diagnosis of Bell's palsy?

Speech or chewing difficulties accompanied by facial droop

A nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which of the following would indicate a basal skull fracture as a result of the injury?

Bloody or clear drainage from the auditory canal

A nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which of the following findings would be associated with spinal shock in this client? Select all that apply.

Bowel sounds are absent. The client's abdomen is distended. Respiratory excursion is diminished. Accessory muscles of respiration are areflexic.

A nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. Which diagnostic test will be prescribed to confirm this diagnosis?

Brain biopsy

A client with Bell's 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 which of the following cranial nerves (CNs)?

CN VII

A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply.

Cerebral angiography Lumbar puncture (LP) Computed tomography

A client with myasthenia gravis is experiencing prolonged periods of weakness. The health care provider prescribes a test dose of edrophonium (Enlon) and the client becomes weaker. The nurse interprets this outcome as:

Cholinergic crisis

A nurse reviews the health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription, if noted in the client's record, should the nurse question?

Clear liquid diet

A nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech will be:

Associated with poor comprehension

A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) is analyzed for protein. The nurse reviews the protein values and notes that the value that supports the diagnosis of Guillain-Barré syndrome is:

75 mg/dL

A 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 an early sign of rupture is which of the following?

A decline in the level of consciousness

A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which of the following?

A lag in closing the bottom eyelid

A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should:

Acknowledge the client's anger and continue to encourage participation in care.

A nurse is preparing a client who is scheduled to have cerebral angiography performed. The nurse should check the client for:

Allergy to iodine or shellfish

A nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history will have the least amount of added risk for neurological problems?

Allergy to pollen

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

Allowing the client's bladder to become distended

An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which of the following is unlikely to be the cause of the client's disorientation?

Alzheimer's disease

A nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which of the following is indicative of this complication of a spinal cord injury?

Areflexia below the level of injury

The nurse is collecting neurological data on an unconscious client. On application of a central noxious stimulus, the nurse observes this response (refer to figure). How should the nurse document this response on the client's record?

Client demonstrated decerebrate posturing.

A nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to read about seizures and related documentation points if the student stated that it is important to document:

Client's diet in the 2 hours preceding seizure activity

A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which of the following to determine whether the client is ready to begin sitting up?

Compares the client's pulse and blood pressure when both flat and sitting

A nurse is trying to communicate with a brain attack (stroke) client with aphasia. Which action by the nurse would be least helpful to the client?

Completing the sentences that the client cannot finish

A nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which of the following indicates an early sign of increased ICP?

Confusion

A nurse is collecting data on a client with Parkinson's disease. Which finding indicates a serious complication of this disorder?

Congested cough and coarse rhonchi heard on auscultation

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

Consciously think about walking over imaginary lines on the floor.

A nurse is caring for the client with a head injury secondary to a motor vehicle accident. The nurse observes the client's status regularly, monitoring closely for which changes in vital signs?

Decreasing pulse, decreasing respirations, increasing BP

A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the health care provider, and the nurse anticipates a prescription for which of the following medications?

Desmopressin (DDAVP)

A nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. Which clinical manifestation is considered a primary symptom of this syndrome?

Development of muscle weakness

A nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which of the following findings? Select all that apply.

Drainage from ear Bruising around the eyes Pink-tinged drainage from the nose

A nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. The initial nursing action is to:

Elevate the head of the bed.

A nurse determines that motor function of which cranial nerve is intact if the client can perform this action? Refer to figure.

Facial

A nurse is caring for a client with a spinal cord injury. The nurse prepares to place high-top sneakers on the client's feet to prevent the occurrence of:

Footdrop

A nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. The nurse assists in developing a plan of care, knowing that which of the following is a characteristic of early Alzheimer's disease?

Forgetfulness

A client with Guillain-Barré syndrome 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 of the following information in discussions with the client?

Generally, a vast number of people recover from this condition.

A client who is recovering from a brain attack (stroke) has residual dysphagia. The licensed practical nurse instructs the nursing assistant to avoid which of the following at mealtime?

Giving the client thin liquids

A client with a brain attack (stroke) has residual dysphagia. When a diet prescription is initiated, the nurse avoids doing which of the following?

Giving the client thin liquids

A nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. The best way for the nurse to explore issues with the client regarding this behavior is to:

Have the client express the feelings in writing.

A nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively?

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

A nurse is positioning the client with increased intracranial pressure (ICP). Which position should the nurse avoid?

Head turned to the side

A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) protein is 750 mg/dL. The nurse analyzes these results as:

Higher than normal supporting the diagnosis of Guillain-Barré

A nurse is collecting neurological data on a post-stroke adult client. Which of the following techniques will the nurse perform to adequately check proprioception?

Hold the sides of the client's great toe and, while moving it, ask what position it is in.

A nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 (thoracic 3) level if which of the following clinical manifestations are observed?

Hypotension and bradycardia

A nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, the nurse plans activities that will:

Increase the client's awareness of the affected side.

A nurse is planning care for a client with Bell's palsy. Which measure should be included in the plan?

Instill artificial tears and wear a patch over the affected eye at night.

The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. The nurse intervenes, based on the understanding that:

It is possible the client can hear the family.

A nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids doing which of the following when managing this client's environment?

Keeping the bed position raised to the nurse's waist level

A nurse is assisting to care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?

Leakage of clear fluid from the nose.

A nurse is assisting in caring for a client with a supratentorial lesion. The nurse monitors which of the following as the critical index of central nervous system (CNS) dysfunction?

Level of consciousness

A nurse is assisting in caring for a client with a suspected diagnosis of meningitis. The nurse reinforces to the client information regarding which diagnostic test that is commonly used to confirm this diagnosis?

Lumbar puncture

A nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse interprets that the client:

May likely have perceptual and spatial disabilities

A thymectomy via a median sternotomy approach is performed on a client with a diagnosis of myasthenia gravis. The nurse has assisted in developing a plan of care for the client and includes which of the following in the plan?

Monitor the chest tube drainage.

A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.

Monitor the client's ability to void. Maintain the client in a flat position. Monitor the client's ability to move the extremities. Inspect the puncture site for swelling, redness, and drainage.

A 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 of the following does the nurse document in the plan as the priority nursing intervention for this client?

Monitor urine output.

A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client?

Monitoring the respiratory rate

A nurse is preparing to care for a client with a diagnosis of brain attack (stroke). The nurse notes in the client's record that the client has anosognosia. The nurse plans care, knowing that the client will:

Neglect the affected side.

A client recovering from a craniotomy complains of a "runny nose." Based on the interpretation of the client's complaint, the best nursing action is to:

Notify the registered nurse.

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

Observe the client feeding himself or herself.

A clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. The nurse notes that the client is prescribed selegiline hydrochloride (Eldepryl). The nurse understands that this medication is prescribed for which diagnosis?

Parkinson's disease

A client with a brain attack (stroke) is experiencing residual dysphagia. The nurse would remove which of the following food items that arrived on the client's meal tray from the dietary department?

Peas

A nurse is assisting in checking for Tinel's sign in a client suspected of having carpal tunnel syndrome (CTS). Which technique would 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.

When the nurse taps at the level of the client's facial nerve, the following response is noted (refer to figure). How should the nurse document this finding on the client record?

Positive Chvostek's sign

A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. (Refer to figure.) How should the nurse record this finding on the client's medical record?

Positive Kernig's sign

A nurse is collecting admission data on a client with Parkinson's disease. 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 of the following in the client's record?

Positive Romberg's test

A client has just undergone lumbar puncture (LP). The nurse assists the client into which most optimal position if tolerated by the client?

Prone, with a pillow under the abdomen

A nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which of the following will provide the nurse with the best information about recovery from the spinal shock?

Reflexes

A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse would avoid which of the following actions in the care of the client?

Removing the weights when repositioning the client

An emergency department nurse is assigned to assist in caring for a client who has suffered a head injury following a motor vehicle accident. The nurse understands that the initial data collection should focus on which of the following?

Respiratory status

A nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client should be maintained in which of the following positions?

Semi-Fowler's position

A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which of the following signs and symptoms? Select all that apply.

Tachycardia Photophobia Red, macular rash Positive Kernig's sign

A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply.

Tea and coffee are restricted on the day of the test. The test will take between 45 minutes and 2 hours. The hair should be washed the evening before the test.

A nurse is told in report that a client has a positive Chvostek's sign. What other data would the nurse expect to find on data collection? Select all that apply.

Tetany Diarrhea Possible seizure activity Positive Trousseau's sign

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

The client complains of a headache and the blood pressure is elevated.

A client with quadriplegia complains bitterly about the nurse's slow response to the call light and the rigidity of the therapy schedule. Which interpretation of this behavior would serve as a basis for planning nursing care?

The client is reacting to loss of control.

A nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign if noted in the client would the nurse report immediately?

The client vomits.

A nurse is caring for a client that is comatose and notes in the client's chart that the client is exhibiting decerebrate posturing. The nurse understands that decerebrate posturing is characterized by:

The extension of the extremities and pronation of the arms

A nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. Which documented early symptom supports this diagnosis?

Vertigo

A nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated?

Restrain the client's limbs.

A nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will:

Rock back and forth to start movement with bradykinesia.

The nurse caring for an older adult client understands that which of the following can increase disorientation in this client? Select all that apply.

Sedatives Anesthesia Physical restraints Analgesics

A nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply.

Suction machine Oxygen administration Padding for the side rails Prescribed diazepam (Valium)

A nurse is caring for a client with increased intracranial pressure (ICP). The nurse should monitor for which of the following trends in vital signs that would occur if ICP is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure (BP)

A nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria if the client:

Indicates that facial puffiness will be a permanent problem

Which of the following information will the nurse reinforce to the client scheduled for a lumbar puncture?

An informed consent will be required.

A client with spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of recurrence?

Limiting bladder catheterization to once every 12 hours

A client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should avoid which of the following when planning care for this client?

Removing the weights to reposition the client

A nurse is monitoring a client with a head injury and notes that the client is assuming this posture. The nurse notifies the registered nurse immediately to report that the client is exhibiting: Refer to figure.

Decorticate posturing

A nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?

Electrodes will be injected into the skeletal muscles.

A nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:

Taking medications on time to maintain therapeutic blood levels

A client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse would plan on leaving the cervical collar in place until:

The result of spinal x-rays is known.

A nurse is administering mouth care to an unconscious client. The nurse should avoid doing which of the following?

Using products with lemon or alcohol

A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which of the following items?

Walker

A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will:

Wear the patch continuously, alternating eyes each day.

An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 AM. The nurse should first determine which of the following about the client?

Whether this is a change in his usual level of orientation

A nurse is planning care for the client with hemiparesis of the right arm and leg. The nurse incorporates in the care plan placement of objects:

Within the client's reach, on the left side

A nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs additional information if the client made which of the following statements?

"I will try to eat my food either very warm or very cold."

A nurse is caring for a client scheduled for magnetic resonance imaging (MRI). Which instruction does the nurse reinforce to the client?

Earplugs can be worn if the noise from the machine is uncomfortable.

A nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse brings which of the following items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray

An adult client has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. The nurse checks for which of the following negative values if the CSF is normal?

Red blood cells

A nurse is providing care to a client with increased intracranial pressure (ICP). Which approach(es) may be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply.

Reducing environmental noise Maintaining a calm atmosphere Allowing the client uninterrupted time for sleep

A nurse has instructed the family of a brain attack (stroke) client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will:

Remind the client to turn the head to scan the lost visual field.

A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client stated that he or she will:

Resume full activity level immediately.

A nurse is assisting with caring for a client after a craniotomy. The nurse plans to position the client in a:

Semi-Fowler's position

A client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid:

Separates into concentric rings and tests positive for glucose

A nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which of the following is noted?

Severe, throbbing headache

A client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure?

Side-lying, with legs pulled up and head bent down onto the chest

The nurse overhears the term "sundowning" used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. The nurse interprets that this client most likely has a diagnosis of:

Alzheimer's disease

Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. A nurse monitors the client for effectiveness of this medication, knowing that its primary action is to:

Decrease cerebrospinal fluid production.

A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity?

Doing active range of motion to finger joints

A client has just undergone computed tomography (CT) scanning with a contrast medium. The nurse determines that the client understands postprocedure care if the client verbalizes that he or she will:

Drink extra fluids for the day.

A nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further clarification of the instructions if the client states that he or she will:

Drive only during the daytime.

A nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding would be an early indication that the level of consciousness (LOC) is deteriorating?

Drowsiness

A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse would plan which approach as therapeutic in assisting the client to cope with the disease?

Encourage and praise perseverance in exercising and performing ADL.

A nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client?

Encouraging multiple visitors at one time

A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which of the following being done by the family?

Encouraging the client to stand unassisted on the leg

A client with a spinal cord injury expresses little interest in food, and is very particular about the choice of meals that are actually eaten. The nurse interprets that:

Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

A nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder supports this diagnosis?

Mild clumsiness

A client was seen and treated in the emergency department for treatment of a concussion. The nurse determines that the family needs further discharge instructions if they say to bring the client back to the emergency department if which of the following occurs?

Minor headache

A nurse is planning care for a client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury?

Moving the client quickly as one unit

A nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad, because "his feet are always cold at night." The nurse should incorporate which of the following concepts when formulating a response to the family member?

Older adults often have slower neurological response times and are therefore more at risk for burns.

An older client is at risk for falls. When developing an individualized plan of care for this client, the nurse recalls that which concept is least relevant to maintenance of balance for the older client?

Older clients cannot think quickly enough to respond to emergencies.

A client is scheduled for a digital subtraction angiography. The nurse supports the client's understanding that the test is directed toward which outcome?

Providing information about the blood vessels

A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration?

Establishing a toileting schedule

A nurse is caring for a client diagnosed with Bell's palsy 1 week ago. Which of the following data would indicate a potential complication associated with Bell's palsy?

Excessive tearing

A client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which of the following activities?

Exhaling during repositioning

A client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, the nurse immediately:

Raises the head of the bed and removes the noxious stimulus

A nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data would focus on which of the following characteristic of this disease?

Recent memory loss

An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which of the following is consistent with normal findings?

Red blood cells

A nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which of the following measures should the nurse avoid in planning for the client's safety?

Putting a padded tongue blade at the head of the bed

A nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client?

Explaining equipment and procedures on an ongoing basis

A nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client should be asked to:

Extend the tongue.

A nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle accident. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation?

Extension of the extremities and pronation of the arms

Which clinical manifestation is observed in the clonic phase of a seizure?

Extension spasms of the body

A nurse is assigned to care for an adult client who had a brain attack (stroke) and is aphasic. Choose the appropriate interventions for communicating with the client. Select all that apply.

Face the client when talking. Speak slowly and maintain eye contact. Use gestures when talking to enhance words. Give the client directions using short phrases and simple terms.

A nurse is assisting the health care provider in performing a lumbar puncture. The nurse prepares for the procedure by placing the client in which position?

Fetal position

A nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center in the:

Hypothalamus

A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client:

In a quiet, dim room with respiratory and cardiac support available

The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.

In a semi-Fowler's position With the head in a midline position

A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client? Select all that apply.

Listening attentively Asking yes and no questions when able Using a communication board when necessary Repeating what the client said to verify the message

A nurse is reinforcing instructions to a client taking divalproex sodium (Depakote). The nurse tells the client to return to the clinic for follow-up laboratory studies related to which test?

Liver function studies

A nurse is turning a postoperative client who had extensive back surgery yesterday. What turning intervention or position would be best for repositioning this client?

Logrolling

A nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item would be included as part of the precautions?

Maintaining the head of the bed at 15 degrees

A nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure?

Making sure not to suction for longer than 30 seconds

A nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which of the following?

Mask-like facies is a component of Parkinson's disease.

A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has precipitating factors such as:

Omitted doses of medication

A nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the health care provider and reports that the client is exhibiting:

Opisthotonos

A nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure?

Prone with a pillow under the abdomen

A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of:

Prosthetic valve replacement

A client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety?

Provide a clear path for ambulation without obstacles.