Neuro mine

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions? "I should call my doctor if I experience a decrease in my vision." "I may take aspirin for eye discomfort following the surgery." "I can blow my nose to clear out any drainage." "I can lift objects up to 20 pounds."

I should call my doctor if I experience a decrease in my vision." The client should report changes in vision immediately because there should be an improvement in vision after the surgery.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? Aphasia Right-sided neglect Impulsive behavior Inability to read

Impulsive behavior The nurse should expect the client who had a right hemispheric stroke to demonstrate impulsive behavior, poor judgment, and lack of awareness of neurologic deficits.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? Hypoactive deep-tendon reflexes Ascending paralysis Intention tremors Increased lacrimation

Intention tremors Clients who have multiple sclerosis are at risk for motor dysfunction, such as intention tremors, poor coordination, and loss of balance.

A nurse is providing teaching regarding a new prescription for carbidopa-levodopa for a client who has Parkinson's disease. Which of the following client statements indicates an understanding of the teaching? "I should expect a slight increase in my blood pressure while taking this medication." "I should take my medication with a high-protein food." "I should expect my urine to be a darker color." "I will expect it to take up to a week for this medication to work."

"I should expect my urine to be a darker color." Secretions such as saliva, urine, and sweat can darken in color when taking carbidopa-levodopa.

A nurse is assessing a client who has a possible head injury following a motor-vehicle crash. The nurse should recognize that which of the following findings indicates increasing intracranial pressure? Restlessness Dizziness Hypotension Fever

Restlessness Behavioral changes, such as restlessness or irritability, are early manifestations of increased intracranial pressure. `

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include? Apply a pressure dressing to the site for 12 hr. Restrict the client's fluid intake for 24 hr. Ensure the client lies flat for 4 to 8 hr. Administer pain medication every 3 to 4 hr.

Ensure the client lies flat for 4 to 8 hr. The client should lie flat for 4 to 8 hr to prevent cerebrospinal fluid leakage from the puncture site.

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority? Provide for frequent rest periods throughout the day. Medicate for pain on a regular schedule. Monitor pulse oximetry findings. Administer baclofen for spasticity.

Monitor pulse oximetry findings. The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor oxygen saturation to identify respiratory compromise as soon as possible.

A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include? Move head slowly to decrease vertigo. Apply warm packs to the affected ear during acute attacks. Increase intake of foods and fluids high in salt. Administer corticosteroids during acute attacks.

Move head slowly to decrease vertigo. The client should use slow head movements decrease the stimulation of vertigo.

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer? Osmotic diuretics via IV bolus Mydriatic ophthalmic drops Corticosteroid ophthalmic drops Epinephrine via IV bolus

Osmotic diuretics via IV bolus The nurse should administer osmotic diuretics to rapidly reduce intraocular pressure and prevent damage to the eye.

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer? Recombinant tissue plasminogen activator Recombinant factor VIII Nitroglycerin Lidocaine

Recombinant tissue plasminogen activator Recombinant tissue plasminogen activator is a thrombolytic administered to dissolve the blood clot that caused the stroke.

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition? Encourage the client to use the Valsalva maneuver. Administer a diuretic. Perform the Credé maneuver. Stroke the client's inner thigh.

Stroke the client's inner thigh. The nurse can stimulate micturition by stroking the client's inner thigh.

A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the client's medication teaching plan? Rinse with antiseptic mouthwash in place of using dental floss. Use an over-the-counter antihistamine if a rash develops. Slowly taper the medication after 6 consecutive months without seizure activity. Take medications at a consistent time each day to maintain therapeutic blood levels.

Take medications at a consistent time each day to maintain therapeutic blood levels. The client should take antiepileptic medications on a regular schedule to maintain therapeutic blood levels and achieve maximum effect.

A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

The nurse should teach the client to sit with the hips at a 90° angle or less with the knees slightly lower than the hips to avoid hip dislocation.

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply.) Crepitus with joint movement Decreased range of motion of the affected joint Involvement of smaller joints of the body Spongy tissue over the joints Joint pain that resolves with rest

Crepitus with joint movement is correct. Crepitus, a grating sound, is an expected finding of osteoarthritis as loosened bone and cartilage move in the diseased joint. Decreased range of motion of the affected joint is correct. Decreased range of motion is an expected finding of osteoarthritis because the client's pain limits movement. Involvement of smaller joints of the body is incorrect. Osteoarthritis affects larger joints, such as the hips and knees. Spongy tissue over the joints is incorrect. Spongy joint tissue is an expected finding of rheumatoid arthritis, which is an inflammatory disease. Joint pain that resolves with rest is correct. Clients who have osteoarthritis have increased pain with activity and decreased pain with rest.

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first? Administer hydralazine via IV bolus. Loosen the client's clothing. Empty the client's bladder. Elevate the head of the client's bed.

Elevate the head of the client's bed. These assessment findings indicate the client is at greatest risk for autonomic dysreflexia and possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension.

A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse expect? Photophobia Complete blindness Flashes of bright light Pain

Flashes of bright light During retinal detachment, the client can experience flashes of bright light or floating dark spots in the affected eye as the retinal layers separate.

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? Maintain a PaCO2 of approximately 35 mm Hg. Provide small doses of fentanyl via IV bolus for pain management. Monitor body temperature every 1 to 2 hr. Reposition the client every 2 hr.

Maintain a PaCO2 of approximately 35 mm Hg. The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure.

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

Monitor capillary refill at least every 4 hr. The nurse should perform a complete vascular assessment at least every 4 hr to monitor for vascular compromise. Assess the client's neurologic status every 8 hr. The nurse should assess the client's vital signs and neurologic status at least every 4 hr. Maintain the client on droplet precautions. Although the nurse should implement droplet precautions for clients who have bacterial meningitis, standard precautions are sufficient for clients who have viral meningitis. Place the client in a well-lit environment. The nurse should minimize the client's exposure to light from windows and overhead lights as photophobia, or light sensitivity, is a manifestation of viral meningitis.

A nurse is providing teaching for a client who is prescribed alendronate for osteoporosis. Which of the following information should the nurse include in the teaching? Take this medication with 240 mL (8 oz) of milk. Remain upright for 30 min after taking this medication. Expect this medication to increase serum calcium levels. Increase vitamin D intake to promote medication absorption.

Remain upright for 30 min after taking this medication. To prevent esophagitis or esophageal ulcers that can result from alendronate therapy, the client should sit up for 30 min after taking this medication and remain sitting until after eating the first meal of the day.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions? Check the client's cheek on his affected side after eating to be sure no food remains there. Encourage the client to sit upright with his head tilted slightly forward during meals. Provide the client with eating utensils that have large handles. Remind the client to look consciously at both sides of his meal tray.

Remind the client to look consciously at both sides of his meal tray.

A nurse is caring for a client who is 8 hr postoperative following a craniotomy. Which of the following actions should the nurse take? Suction the client every 2 hr. Report wound drainage greater than 50 mL/8 hr. Position the client flat in bed. Assess the client's neurologic status every 8 hr.

Report wound drainage greater than 50 mL/8 hr. Following a craniotomy, the client is at risk for hemorrhage and hypovolemic shock. The nurse should report wound drainage greater than 50 mL/8 hr.

A nurse in the emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurse's priority? Administer artificial tears. Assist with Tensilon test. Administer immunosuppressants. Assist with plasmapheresis.

Assist with Tensilon test. The first action the nurse should take using the nursing process is to assess the client. The Tensilon test will determine if the client is experiencing a myasthenic crisis or a cholinergic crisis.

A nurse is caring for a client in balanced suspension skeletal traction who reports intermittent muscle spasms. Which of the following actions should the nurse take first? Reposition the client. Provide distraction. Administer a muscle relaxant. Check the position of the weights and ropes.

Check the position of the weights and ropes. The first action the nurse should take using the nursing process is to assess the client. The nurse should first check the position of the weights and ropes to determine the cause of the muscle spasms.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? Glasgow Coma Scale score of 15 Intracranial pressure reading of 15 mm Hg Ecchymosis at base of skull Clear drainage from nose

Clear drainage from nose Clear drainage from the nose indicates cerebral spinal fluid is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura.

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching? "There is a test for Alzheimer's disease that can establish a reliable diagnosis." "The goal of medication therapy is to reverse the degenerative changes that can occur in brain tissue." "Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity." "The drugs used to treat Alzheimer's disease can help delay cognitive changes."

"The drugs used to treat Alzheimer's disease can help delay cognitive changes." Medications used to treat Alzheimer's disease enhance the availability of acetylcholine allowing for greater response from cholinergic neurons in the brain.

A nurse is caring for a client who was admitted for status epilepticus and is on seizure precautions. Which of the following actions should the nurse plan to take? Assess hourly for a spike in blood pressure. Maintain the client on bed rest. Keep a padded tongue blade at the bedside. Establish IV access.

A nurse is caring for a client who was admitted for status epilepticus and is on seizure precautions. Which of the following actions should the nurse plan to take? Assess hourly for a spike in blood pressure. Maintain the client on bed rest. Keep a padded tongue blade at the bedside. Establish IV access.

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take? Remind the client that the limb has been removed. Change the dressing on the client's residual limb. Administer an oral dose of gabapentin to the client. Elevate the client's residual limb above heart level.

Administer an oral dose of gabapentin to the client. The nurse should administer a nonopioid medication to the client experiencing phantom limb pain. Gabapentin is an antiepileptic medication and is effective for treatment of phantom limb pain.

A nurse is caring for a client who has a full arm cast and reports pain of 8 on a scale from 0 to 10 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first? Administer additional pain medication. Check the circulation of the affected extremity. Document the findings. Reposition the affected extremity.

Check the circulation of the affected extremity. The greatest risk to the client is neuromuscular injury resulting from compartment syndrome. The first action the nurse should take is to check for impaired circulation of the affected extremity.

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect? Unilateral joint involvement Ulnar deviation Fractures of the spine Decreased sedimentation rate

Ulnar deviation The inflammation that occurs in the hand joints can make them susceptible to deformity from daily use. Ulnar deviation, or lateral deviation of the fingers, can occur from opening jars and other similar motions.