NEURO PrepU 1

"You should review this information with your healthcare provider at every admission."

A 35-year-old client diagnosed with multiple sclerosis three years ago presents the nurse with an advance directive refusing intubation, mechanical ventilation, and tube feedings. How should the nurse respond?

to prevent vision loss

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?

"You're in the hospital. You were in an accident and unconscious."

A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?

jugular vein distention

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?

decreased acetylcholine level

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean them from sedation therapy. A nurse needs further assessment data to determine whether

abort the developing migraine

Ergotamine tartrate is prescribed for a client's migraine headaches. What is an expected outcome of the use of this drug?

semi-Fowler

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

sudden, severe hypertension

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for:

extension posturing

The nurse is assessing a client's motor response after brain surgery. The nurse pinches the client's skin to elicit a response and observes the client's arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response?

maintaining an upright position while eating introducing foods on the unaffected side of the mouth keeping distractions to a minimum

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Check all that apply.

No action is needed at this time because the drug level is normal.

Upon review of a client's phenytoin levels, a nurse notes a value of 16 mcg/ml. What should the nurse do next?

drusen on retina

When assessing a client diagnosed with macular degeneration, the nurse would expect to see which finding?

Carefully test the temperature of bath water. Avoid hot water bottles and heating pads. Inspect the skin daily for injury or pressure points. Wear warm clothing when outside in cold temperatures

Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply.

preparing for mechanical ventilation

Which nursing action addresses the primary concern for a client with Guillain-Barré syndrome?

Promote measures that limit mobility.

The client is diagnosed with a detached retina in the right eye. What should the nurse do first?

Administer atropine sulfate.

The client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out?

Tell the client to march in place.

Which nursing approach is most helpful to a client with Parkinson disease who is experiencing a freezing of gait with difficulty initiating movement?

cones

A client is color blind. The nurse understands that this client has a problem with

exceeding the prescribed exercise program

A client has low back pain. What should the nurse instruct the client to avoid doing?

Implement a bed alarm. Maintain the bed in the lowest position. Offer toileting every 2 to 3 hours. Advise family to notify staff when leaving.

A nurse is caring for a client diagnosed with Alzheimer's disease who scored a 7 (High risk) on the Hendrich II Fall Risk Model. Which nursing interventions would the nurse implement? Select all that apply.

promote carbon dioxide elimination.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to

Use sunglasses that wrap around the side of the face when in bright light.

One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do?

a stiff, masklike facial expression.

When assessing the client with Parkinson's disease, the nurse should observe the client for:

meningeal irritation

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate?

succinylcholine

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent?

administering a stool softener as ordered

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

Refer to primary healthcare provider Have client keep a sleep diary Assess sleep routine/hours

A client who has apnea during sleep would require which of the following interventions? Select all that apply.

admitted 48 hours ago with bacterial meningitis who requires antibiotic administration

A new nurse has been assigned to the neurologic intensive care unit. Which client would be best to assign the nurse? A client:

respiratory acidosis

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

function of the client's left hand before the operation

A nurse is caring for a client who's had surgery to repair a hip fracture. The client says their left hand and arm are numb and they can't move the extremity. The nurse contacts the physician, who suspects brachial plexus nerve damage. What additional priority assessment does the nurse need?

Maintain the client in a flat position, except for logrolling as needed.

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays have not been read, so the nurse does not know whether the client has a cervical spinal injury. The nurse develops a plan of care and includes which action?

decreasing peripheral vision

A client has chronic open-angle glaucoma. What should the nurse ask the client about when conducting a focused assessment?

unequal pupil size

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?

asking the client to speak louder when tired

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?

edrophonium

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an I.V. injection of a medication. What is the medication the nurse tells the client they'll receive during this test?

prevents the medication from entering the tear duct.

After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eye drops. What is the expected outcome of applying pressure?

10 to 20 mm Hg.

When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of

The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply.

Assess capabilities, demonstrate the use of assistive devices, and assess how the client will manage at home.

A client undergoes intense rehabilitation after a cerebrovascular accident (CVA) and is being discharged with residual hemiparesis. What is the most important responsibility of the case manager?

Contact the health care provider.

After cataract removal surgery on the left eye, the client sits up and reports having sharp pain in the operative eye. What should the nurse do next?

Remove any nearby objects that could harm the child.

After teaching a group of schoolteachers about seizures, the teachers role-play a scenario involving a child experiencing a generalized tonic-clonic seizure. Which action, when performed first, indicates that the nurse's teaching has been successful?

lung auscultation and measurement of vital capacity and tidal volume

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

limiting fluid intake to 1,000 mL/day

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate?

absence of reflexes along with flaccid extremities

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

to use the eye medication for the rest of life.

The client asks when to stop taking the eye medication for chronic open-angle glaucoma. The nurse should tell the client:

Wrap the hands in soft "mitten" restraints.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP)?

"Assume a reclining or flat position."

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

Test the nasal drainage for glucose.

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

Check the equipment.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?