Neurosensory

A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions would the nurse include? Select all that apply. 1. Monitor the body for any skin rash. 2. Maintain adequate amounts of fluid and fiber in the diet. 3. Perform good oral hygiene, including daily brushing and flossing. 4. Receive necessary periodic blood work. 5. Report any problems with walking or coordination, slurred speech, or nausea.

1,3,4,5

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply. 1. spontaneous eye opening 2. tachypnea, bradycardia, and hypotension 3. unequal pupil size 4. orientation to person, place, and time 5. pain localization 6. incomprehensible sounds

1,4

A nurse is caring for a client, diagnosed with Alzheimer's disease, who scored a 7 (high risk) on the Hendrich Il Fall Risk Model. Which nursing interventions would the nurse implement? Select all that apply. 1. Implement a bed alarm. 2. Place the overbed table next to bed. 3. Instruct the client to ask for help before ambulating. 4. Maintain the bed in the lowest position. 5. Offer toileting every 2 to 3 hours. 6. Advise family to notify staff when leaving.

1,4,5,6

The nurse is caring for a client who is experiencing an exacercation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply. 1. Eat a low-purine dies. 2. Limit fluid intake to no more than 1 L/day. 3. Eat a high-protein diet, with at least two servings of lean meat per day. 4. Limit sodium intake to 1,500 mg/day. 5. Limit alcohol intake.

1,5

A nurse is caring for a client diagnosed with a cerebral aneurysm. The health care provider orders hydralazine 15 mg intravenously every 4 hours as needed to keep the systolic blood pressure less than 140 mm Hg. To administer the correct dose, how many milliliters of medication would the nurse draw up in the syringe? Record your answer using two decimal places.

0.75

A nurse is monitoring a client's intracranial pressure (ICP) after a traumatic head injury. The health care provider calls and asks for a report on the client's condition. Based on the documentation below, how would the nurse respond? 1. "The client's ICP remains elevated." 2. "The client's ICP has decreased to lower than normal limits." 3. "The client's ICP is within normal limits." 4. "The client's ICP was elevated but now has returned to normal."

1

The nurse is caring for a client who sustained a head injury during a football game. The nurse is completing the following examination. Which documentation by the nurse provides normal results of this examination? 1. The client's pupils are equal and reactive to light and accommodation. 2. The client's retina is attached, with no signs of tearing. 3. The client's vision is 20/20 in both eyes. 4. The client's visual field is 360°.

1

The nurse is caring for a client who is scheduled to undergo a computed tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information would the nurse include in a preprocedural teaching plan? Select all that apply. 1. The test may require removal of watches, bracelets, or earrings. 2. A contrast dye may be given before the test. 3. Throat irritation and facial flushing may occur if contrast dye is used. 4. All medications must be withheld for 12 hours prior to the procedure. 5. The CT scan is considered an invasive procedure, but not dangerous. 6. It is necessary to report any known allergies to iodine or seafood prior to the procedure.

1,2,3,6

A nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and blood pressure of 174/100 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for this client? Select all that apply. 1. Elevate the head of the bed to 90°. 2. Loosen constrictive clothing. 3. Use a fan to reduce diaphoresis. 4. Assess for bladder distention and bowel impaction. 5. Administer antihypertensive medication as ordered. 6. Administer morphine as ordered.

1,2,4,5

A nurse assesses a client with suspected bacterial meningitis. Which documented findings of meningeal irritation suggest this diagnosis? Select all that apply. 1. tinnitus 2. nuchal rigidity 3. positive Brudzinski's sign 4. positive Kernig's sign 5. babinski's reflex 6. photophobia

2,3,4,6

A nurse is assessing a clients extraocular eye movements as part of evaluating neurological func-tioning. This documents the status of which cranial nerves? Select all that apply. 1. optic (Il) 2. oculomotor(III) 3. trochlear (IV) 4. trigeminal (V) 5. abducens (VI) 6. acoustic (VIII)

2,3,5

A client presents to the emergency department with right facial droop and drooling. A diagnosis of Bell's palsy is confirmed by a neurological exam and magnetic resonance imaging (MRI). When instructing the spouse on the interventions needed to care for the client, which spouse statements need clarification by the nurse? Select all that apply. 1. "I will buy a clothing protector for feedings." 2. "I will obtain a walker in case symptoms progress." 3. "I will instill eye drops to prevent symptoms of dry eyes." 4. "I will watch for further symptoms of a stroke. 5. "I will reinforce that symptoms are usually temporary." 6. "I will provide sunglasses during the daytime."

2,4

The rehabilitation nurse is caring for a client with a health history of multiple sclerosis (MS) for 10 years. Recently, the nurse has seen a significant decline in the client's function. When reevaluating the client's plan of care, the nurse considers the client's physiologic changes associated with the decline. Arrange the following degenerative changes in the order in which they occur. All options must be used. 1. degeneration of axons 2. demyelination throughout the central nervous system 3. periodic and unpredictable exacerbations and remissions 4. plaque formation that interrupts nerve impulses 5. the immune system attacks myelin

5,2,1,4,3

A nurse is preparing to teach students in a health class about hearing pathways. Place the following steps in chronological order to match how the nurse would describe the normal pathway of sound wave transmission and hearing to the class. All options must be used. 1. interpretation of sound by the cerebral cortex 2. transmission of vibrations through the hammer, anvil, and stirrup 3. stimulation of nerve impulses in the inner ear 4. transmission of vibrations to the auditory area of the cerebral cortex 5. collection of the sound waves in the pinna

5,2,3,4,1

A client is scheduled to undergo cerebral angiography to allow for examination of the cerebral arteries. Place the following interventions in the order in which the nurse would perform them. All options must be used. 1. Administer antianxiety medication if ordered. 2. Confirm no allergies to iodine, seafood, or radiopaque dyes. 3. Make sure the client has signed an informed consent form. 4. Maintain the affected extremity in straight alignment for 6 hours as ordered. 5. Encourage the client to verbalize questions about the procedure with nurse and health care provider.

5,3,2,1,4

The nurse is preparing to administer phenytoin to a 99-Ib (45 kg) client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin would be administered in the first dose? Record your answer as a whole number.

75