neuro

The nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which question?

"Are you getting up at night to urinate?"

A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse should 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 female client with myasthenia gravis comes to the primary 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. Which is the appropriate nursing response?

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

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 makes which statement?

"I can resume a full activity level immediately."

The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement?

"I can't swallow very well today."

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

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

The nurse has given medication instructions to the client receiving phenytoin. The nurse determines that the client understands the instructions if the client makes which comments? Select all that apply.

"I should not suddenly stop taking this medication." "Good oral hygiene is needed, including brushing and flossing."

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

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

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

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

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

"I will drink extra fluids for the day."

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

"I will drive only during the daytime."

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

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

The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement?

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

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." An appropriate response by the nurse is which?

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

The nurse is caring for a client with a diagnosis of multiple sclerosis (MS) who has been prescribed amantadine. The client asks the nurse why the amantadine has been prescribed. Which response should the nurse make?

"It is prescribed to relieve fatigue."

The 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 further teaching if the client makes which statement?

"Resting in a sauna will be a relaxing form of activity."

Family members of an elderly client ask the nurse if there is any test to determine if a person will eventually get Alzheimer's disease? Which appropriate response should the nurse make?

"There are no tests to determine if a person will get Alzheimer's disease, but research for new diagnostic tests will continue."

The nurse is caring for a client following a craniotomy in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to the Figure.

A

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

A decline in the level of consciousness

Which symptoms would validate the diagnosis of a cluster headache? Select all that apply.

A runny nose Burning sensation in the eye Tearing on the affected eye

A client with myasthenia gravis becomes increasingly weaker. The primary health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if the client is in cholinergic crisis?

A temporary worsening of the condition

A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse?

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

The nurse is caring for a client with the diagnosis of myasthenia gravis. Which primary health care provider's prescription should the nurse question?

Administer the prescribed anticholinesterase medication 30 minutes after meals.

The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure?

Allergy to iodine or shellfish

The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems?

Allergy to pollen

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

Allowing the 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 is unlikely to be the cause of the client's disorientation?

Alzheimer's disease

The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The primary health care provider gives a test dose of edrophonium. The nurse recalls that the client should have which reaction if the client has this disease?

An increase in muscle strength within 1 to 3 minutes

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

An informed consent will be required.

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

Areflexia below the level of injury

The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action?

Assist the client to the floor.

The 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 should fit which characterization?

Associated with poor comprehension

The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which 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.

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

Brain biopsy

A client with Parkinson's disease is developing dementia. Which action should the nurse plan to assist the client in maintaining self-care abilities?

Break down activities into small steps.

The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Select all that apply.

Bruising behind ears ("Battle's sign") Bruising around eyes ("raccoon eyes") Bloody or clear drainage from the auditory canal

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 cranial nerve (CN)?

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 primary health care provider prescribes a test dose of edrophonium and the client becomes weaker. The nurse interprets this outcome as indicative of which result?

Cholinergic crisis

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

Clear liquid diet

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

Client demonstrated decerebrate posturing.

The 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 research seizures and related documentation points if the student states which assessment is important?

Client's diet in the 2 hours preceding seizure activity

The nurse is preparing to give the postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." The nurse should formulate a response based on which understanding of codeine?

Codeine does not alter respirations or mask neurological signs as do other opioids.

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

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

The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client?

Comparing the amount of prescribed weights with the amount in use

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

Completing the sentences that the client cannot finish

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

Confusion

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

Congested cough and coarse rhonchi heard during 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.

The nurse is monitoring a client with a head injury and notes that the client is assuming the posture shown in the figure. What is the client exhibiting that would require the nurse to notify the registered nurse immediately? Refer to the figure.

Decorticate posturing

Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. The nurse monitors the client for effectiveness of this medication, knowing which is its primary action?

Decrease cerebrospinal fluid production

An adult client with suspected meningitis has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis of a bacterial infection. The nurse checks for which value indicating a bacterial infection of the CSF?

Decreased glucose level

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

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 primary health care provider, and the nurse anticipates a prescription for which medication?

Desmopressin

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. Which sign/symptom is considered a primary symptom of this syndrome?

Development of muscle weakness

The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data should focus on which characteristics of this disease? Select all that apply.

Difficulty learning Recent memory loss

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

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

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

The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which findings are early indications that the level of consciousness (LOC) is deteriorating? Select all that apply.

Drowsiness Less frequent speech Slight slurring of speech

The 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 should bring which items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray

The 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. Which is the initial nursing action?

Elevate the head of the bed.

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

Encourage and praise perseverance in exercising and performing ADL.

The 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 there is a need for further teaching if the nurse observes which action by the family?

Encouraging the client to stand unassisted on the leg

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

Establishing a toileting schedule

The nurse is caring for a client who was diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy?

Excessive tearing

A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observations? Select all that apply.

Excessive tearing Inability to furrow brow A lag in closing the bottom eyelid

The 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 activity?

Exhaling during repositioning

The 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

The 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 perform which action?

Extend the tongue.

The nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle crash. 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

The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use 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.

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

Facial

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

Flat, turning from side to side as needed

The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which?

Foot drop

The 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 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 information in discussions with the client?

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

A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should avoid which action?

Giving the client thin liquids

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

Have the client express the feelings in writing.

The 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

The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse?

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 which?

Higher than normal, supporting the diagnosis of Guillain-Barré

A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which findings noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Select all that apply.

Hip replacement Permanent pacemaker Prosthetic valve replacement

The nurse is collecting neurological data on a poststroke adult client. Which technique should 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.

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

Hypotension and bradycardia

The 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 which is located in which part of the brain?

Hypothalamus

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

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

The 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, which action does the nurse plan?

Increase the client's awareness of the affected side.

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

The 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 when the client indicates which altered personal appearance?

Indicates that facial puffiness will be a permanent problem

The 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. How should the nurse interpret the client's situation?

It is possible the client can hear the family.

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

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

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

Level of consciousness

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

Limiting bladder catheterization to once every 12 hours

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

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

Liver function studies

The 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

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

Maintaining the head of the bed at 15 degrees

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

Masklike facies is a component of Parkinson's disease.

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. How should the nurse interpret this?

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

The nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). Which initial sign/symptom of this disorder supports this diagnosis?

Mild clumsiness

The 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.

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

Monitor urine output.

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

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

Moving the client quickly as one unit

Which signs/symptoms are observed in the clonic phase of a seizure? Select all that apply.

Muscular relaxation Extension spasms of the body Contortion of the face with eye rolling

A client receives a dose of edrophonium. The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process?

Myasthenia gravis

A client recovering from a craniotomy complains of a "runny nose." Based on the interpretation of the client's complaint, which action should the nurse take?

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?

Observe the client feeding himself or herself.

A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor?

Omitted doses of medication

The 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 registered nurse and reports that the client is exhibiting which?

Opisthotonos

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply.

Pad the bed's side rails. Place an airway at the bedside. Place oxygen equipment at the bedside. Place suction equipment at the bedside.

The 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. The nurse understands that this medication is prescribed for which disorder?

Parkinson's disease

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

Peas

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

Percuss the medial nerve at the wrist as it enters the carpal tunnel, and monitor for tingling sensations.

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

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. How should the nurse record this finding on the client's medical record? Refer to figure.

Positive Kernig's sign

The 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 in the client's record?

Positive Romberg's test

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

Provide a clear path for ambulation without obstacles.

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

Putting a padded tongue blade at the head of the bed

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take?

Raise the head of the bed and remove the noxious stimulus.

An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets which finding as abnormal if present?

Red blood cells

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would 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

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

Reflexes

The nurse is reinforcing instructions to the family of a 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 do which?

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

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

Removing the weights when repositioning the client

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions by the nurse would be contraindicated? Select all that apply.

Restrain the client's limbs. Consider insertion of a padded tongue blade.

The 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 perform which activity?

Rock back and forth to start movement slowly.

The 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 position?

Semi-Fowler's position

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply.

Semi-Fowler's position With the foot of the bed flat

The 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 meets which criteria?

Separates into concentric rings and tests positive for glucose

The 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 sign/symptom is noted?

Severe, throbbing headache

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

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

The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complications of hypothermia blanket use? Select all that apply.

Skin breakdown Diminished peripheral perfusion

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

Speech or chewing difficulties accompanied by facial droop

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

Suctioning for longer than 30 seconds

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

Tachycardia Photophobia Red, macular rash Positive Kernig's sign

The 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 which activity?

Taking medications on time to maintain therapeutic blood levels

The nurse is told in report that a client has a positive Chvostek's sign. Which other data should 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 tetraplegia complains bitterly about the nurse's slow response to the call light and the rigidity of the therapy schedule. Which interpretation of this behavior should serve as a basis for planning nursing care?

The client is reacting to loss of control.

The 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 makes which determination?

The client may have perceptual and spatial disabilities.

The 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 which is a characteristic of anosognosia?

The client neglects the affected side.

The 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, should the nurse report immediately?

The client vomits.

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time?

The primary health care provider (PHCP) reviews the x-ray results.

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. Which documented symptoms support this diagnosis? Select all that apply.

Vertigo Balance and coordination problems

A client is suspected of having a diagnosis of Guillain-Barré syndrome (GBS). Which findings would support a diagnosis of Guillain-Barré syndrome? Select all that apply.

Visual and hearing disturbances Ascending symmetrical muscle weakness

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 item?

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 do which?

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 about the client?

Whether this is a change in his usual level of orientation

The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client?

Within the client's reach, on the left side