Neurosensory Prep-U

The client with a cataract tells the nurse about being afraid of being awake during eye surgery. Which response by the nurse would be the most appropriate?

"What is it that disturbs you about the idea of being awake?"

Which of the following statements indicates the client has understood the instructions to follow at home after cataract surgery?

"I should not bend over to pick up objects from the floor."

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why am I unable to stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior?

"Reviewing your losses is a way to help you work through your grief and loss."

The nurse has administered mannitol I.V. Which of the following is a priority assessment for the nurse to make after administering this drug?

Monitor urine output.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?

XII

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should:

stay with the client and encourage him to eat.

A client with an inoperable brain tumor is brought to the hospital because the family can no longer care for the client at home. As the nurse provides care for the client, family members express their disappointment at not being able care for him/her at home as the client wished, since he/she did not want to die in the hospital. Which response by the nurse is best?

"Have you explored hospice care? I can ask the case manager to discuss this care option with you, if you're interested."

Which of the following interventions would likely be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery?

Applying ice compresses.

The nurse is preparing to administer propranolol to a client for control of migraine headaches. The client also has a prescription for sumatriptan as needed for a headache. The client's pulse rate is 56 bpm. What should the nurse do next?

Assess blood pressure.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

A client has short-term memory loss. Which of the following nursing actions would be appropriate to help the client cope with memory loss?

Place a single-date calendar where the client can view it.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?

Trigeminal neuralgia

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium test.

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

asking the client to speak louder when tired

The nurse is assessing a client for decerebrate posturing. The nurse should assess the client for:

back arched, rigid extension of all four extremities.

A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client's nursing care with the understanding that acute angle-closure glaucoma:

is a medical emergency that can rapidly lead to blindness.

The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:

monitor the temperature of the bathwater. Rationale: thalamus controls sensory perception

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply.

• "I'll try to chew my food on the unaffected side." • "Drinking fluids at room temperature should reduce pain." • "If brushing my teeth is too painful, I'll try to rinse my mouth instead."

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.

• Elevate the head of the bed 15 to 20 degrees. • Contact the health care provider (HCP) if ICP is greater than 15 mm Hg. • Monitor neurologic status using the Glasgow Coma Scale.

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability?

"I can participate in sexual activity but might not experience orgasm."

Which of the following is contraindicated for a client with seizure precautions?

Assessing oral temperature with a glass thermometer.

For a neurologically injured client, the nurse would best assess motor strength by:

Comparing equality of hand grasps.

When completing a nursing assessment on a client admitted with a neck injury, which of the following findings would indicate an incomplete spinal cord injury (SCI)?

Evidence of voluntary motor and sensory function below the level of injury

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for:

Expressive aphasia.

A client with glaucoma is to receive 3 gtt of acetazolamide in the left eye. What should the nurse do?

Have the client look up while the nurse administers the eyedrops.

A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?

Head trauma.

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?

Lung auscultation and measurement of vital capacity and tidal volume

The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors?

The tremors sometimes disappear with purposeful and voluntary movements.

Follwing a transsphenoidal hypophysectomy, the nurse should assess the client for:

cerebrospinal fluid (CSF) leak.

To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:

coughing.

The nurse should assess clients with chronic open-angle glaucoma (COAG) for:

decreasing peripheral vision.

After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders pilocarpine ophthalmic solution, 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by:

instilling one drop of pilocarpine 0.25% into both eyes four times daily.

The client reports that the nasal packing is uncomfortable and asks when it will be removed. The nurse should tell the client the nasal packing is usually removed:

24 to 48 hours after surgery.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep his leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take?

Ask the staffing coordinator to assign a nursing assistant to sit with the client.

A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which of the following actions is most important for the nurse to take to facilitate rehabilitation with eating?

Assist the client in learning to eat with the left hand.

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent?

Contractures.

Which of the following nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?

Disorientation, increasing blood pressure, bradycardia, and bradypnea

Which of the following approaches to chronic pain management is most effective?

Multidisciplinary approach.

Which goal is a priority for a client who has undergone surgery for retinal detachment?

Prevent an increase in intraocular pressure.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

After the client returns from surgery for a deviated nasal septum, the nurse should place the client in what position?

Semi-Fowler's.

A client who has glaucoma has been prescribed timolol eyedrops. The nurse should give which instructions about the administration of the eyedrops?

The medication may cause some transient eye discomfort.

A nurse is caring for a female client following a motor vehicle accident resulting in paraplegia. The client is ready for discharge to home with her husband, who states, "I'm scared to carry her because I'm afraid I'll either hurt my back or drop her." A nurse identifies a need for discharge teaching of the husband in regard to:

ergonomic principles and body mechanics.

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

evaluation of the corneal reflex response.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners.

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)?

Administering a stool softener as ordered

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?

Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.