Neurosensory ATI

A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. What statements by the client indicates an understanding of the teaching? a. an aura is a sensory warning that a seizure is imminent b. an aura is a continuous seizure in which seizures occur in rapid succession c. an aura is a period of sleepiness following a seizure d. an aura is a brief loss of consciousness accompanied by staring

a. an aura is a sensory warning that a seizure is imminent An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor.

A nurse is performing a neurologic assessment for a client who has a brain tumor. What finding should indicate to the nurse cranial nerve involvement? a. dysphagia b. positive babinski sign c. decreased deep-tendon reflexes d. ataxia

a. dysphagia

A nurse is providing teaching to the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that what manifestations is the priority? a. dysphagia b. emotional lability c. impaired speech d. self-care dependency

a. dysphagia The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning, which is having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and should be the nurse's priority concern. When applying the ABC priority-setting framework, the airway is the priority because it must be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, dysphagia is the priority manifestation because it can lead to aspiration.

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. What reaction should the nurse anticipate when drawing a blood sample? a. rigidly extends arms b. internally flexes wrists c. curls into fetal position d. internally rotates his legs

a. rigidly extends arms

A nurse is assessing a client who has a new diagnosis of mastoiditis. What manifestation should the nurse expect? a. swelling behind the affected ear b. facial drooping on the affected side c. nystagmus on the affected side d. pearly gray color of the affected eardrum

a. swelling behind the affected ear

A nurse is assessing a client who has a closed head injury and has received mannitol for manifestations of increased intracranial pressure. What findings should indicate to the nurse that the med is having a therapeutic effect? a. the client's serum osmolarity is 310 mOsm/L b. the client's pupils are dilated c. the client's heart rate is 56/min d. the client is restless

a. the client's serum osmolarity is 310 mOsm/L Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.

A nurse is assessing a client who has sustained a recent head injury. What finding should the nurse recognize as a manifestation of increased intracranial pressure? a. widened pulse pressure b. tachycardia c. periorbital edema d. decreased in urine output

a. widened pulse pressure

A nurse is providing discharge teaching to a client who is postop following cataract surgery and has an intraocular lens implant. What statement by the client indicates an understanding of the instructions? a. I will sleep on the affected side b. I will avoid bending over c. I will restrict my caffeine d. I will take aspirin to relieve my pain

b. I will avoid bending over The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can result in intraocular hemorrhage.

A nurse is assessing a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? a. orthopnea b. cheyne-stokes c. paradoxical d. kussmaul

b. cheyne-stokes

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. What instructions should the nurse include in the teaching? a. place a warm compress on your forehead b. darken the lights c. light a scented candle d. drink a caffeinated beverage

b. darken the lights

A nurse in a rehab center is performing an assessment for a client who is recovering from a left-hemisphere stroke. What finding should the nurse expect? a. reduced left-side motor function b. difficulty with speech c. impulsive behavior d. neglect of the left side of the body

b. difficulty with speech

A nurse is reviewing the lab result of a lumbar puncture for a client who has manifestations of bacterial meningitis. What finding should the nurse expect? a. elevated glucose b. elevated protein c. presence of RBCs d. presence of D-dimer

b. elevated protein An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase of protein in the cerebrospinal fluid.

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take what action first in the event of a seizure? a. reorient the client b. protect the client's head c. loosen constrictive clothing d. turn the client on his side

b. protect the client's head The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The client is at greatest risk for injury from hitting his head; therefore, the first action is to protect the client's head from injury.

A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS? a. sensory dysfunction b. weakness of the distal extremities c. decreased vision d. aletered temp regulation

b. weakness of the distal extremities

A nurse is providing discharge teaching to a client who is postop following scleral buckling to repair a detached retina. What instructions should the nurse include in the teaching? a. you can expect your vision to return immediately after the procedure b. you should avoid reading for 1 week c. you can remove eye shields when you are sleeping d. you should not lift objects that are more than 25 lbs.

b. you should avoid reading for 1 week

A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. What is the priority assessment data the nurse should collect to determine a change in the client's neurologic status? a. vital signs b. body posture c. LOC d. exam of pupils

c. LOC The nurse should apply the urgent vs. nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority because they pose more of a risk to the client. The nurse might also use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify the most urgent finding. Therefore, the priority assessment is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurologic status.

A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. What instructions should the nurse include in the teaching? a. avoid bearing down b. increase caffeine intake c. avoid sudden movements d. increase sodium intake

c. avoid sudden movements Ménière's disease is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. What instructions should the nurse include in the teaching? a. dry the ear canal with a cotton swab after swimming b. apply an ice pack to the ear to relieve pain c. instill a diluted alcohol solution into the ear after swimming d. irrigate the ear with cool tap water to clean

c. instill a diluted alcohol solution into the ear after swimming External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal.

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. What supplies should the nurse place at the client's bedside? a. metered-dose inhaler b. continuous passive motion machine c. oral-nasal suction equipment d. external defib pads

c. oral-nasal suction equipment The client who has myasthenia gravis is at risk for aspiration because of progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.

A nurse is caring for a client who is postop following a frontal craniotomy. The nurse should place the client in what position? a. trendelenburg b. prone c. semi-fowlers d. sims

c. semi-fowlers

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? a. multiple floaters b. flashes of light in front of the eye c. severe eye pain d. double vision

c. severe eye pain Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headache, brow pain, and nausea and vomiting.

A nurse is assessing a client who has Guillain-Barre syndrome. What finding should the nurse expect? a. tonic-clonic seizures b. report of a severe headache c. weakness in the lower extremities d. decreased LOC

c. weakness in the lower extremities

A nurse is assessing a client who is postop following a craniotomy and has urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus. What lab values should the nurse plan to obtain to assess DI? a. BUN b. Blood glucose c. Urine ketones d. Specific gravity

d. Specific gravity

A nurse is providing teaching to a class about TIAs. What info should the nurse include in the teaching? a. can cause irreversible hemiparesis b. can be the result of cerebral bleeding c. can cause cerebral edema d. can precede an ischemic stroke

d. can precede an ischemic stroke

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). What information should the nurse include in the teaching? (select all) a. lost vision can improve with eye drops b. administer eye drops as needed for vision loss c. glasses will be necessary to correct the accompanying presbyopia d. driving can be dangerous due to the loss of peripheral vision e. laser surgery can help reestablish the flow of aqueous fluid

d. driving can be dangerous due to the loss of peripheral vision e. laser surgery can help reestablish the flow of aqueous fluid

A nurse is teaching a client who has myopia laser-assisted in situ keratomileusis surgery. The nurse should include in the teaching that what is an adverse effect of Lasik surgery? a. eyelid twitching b. photosensitivity c. introcular hemorrhage d. dry eyes

d. dry eyes

A nurse is teaching a class of new parents about otitis media. What manifestations should the nurse include in the teaching? a. high-pitched sound heard in the ear b. intermittent rapid eye movement c. itching on the external canal d. feeling of fullness in the ear

d. feeling of fullness in the ear

A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease. What info should the nurse include in the teaching? a. place abstract pictures on the wall of the client's room b. provide music for the client using headphones c. reorient the client to reality frequently d. limit choices offered to the client

d. limit choices offered to the client

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify what findings as a manifestation of autonomic dysreflexia? a. flushing of the lower extremities b. hypotension c. tachycardia d. report of a headache

d. report of a headache Autonomic dysreflexia is a neurologic emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

A nurse is reviewing the medical hx of a client who is scheduled for MRI exam of the c-spine. The nurse should alert the provider to what info in the client's hx that is a contraindication to the procedure? a. the client has a new tattoo b. the client is unable to sit upright c. the client has a hx of PVD d. the client has a pacemaker

d. the client has a pacemaker