Neurosensory Test

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include?

"Avoid driving until the medication's effects are evident"

A nurse is caring for a client following a complete spinal cord transection injury. The client's family asks the nurse what the term paraplegia means. Which of the following responses should the nurse make?

"He is unable to move his lower body and legs/"

A nurse is reinforcing teaching with a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client should the nurse identify as understanding of the teaching?

"I can take medications up to 2 hr before the procedure."

a nurse is evaluating discharge instructions for aclient following a right cataract extraction. Which of the following client statements indicates the teaching is effective?

"I will take a stool softener until my eye is healed."

A nurse is reinforcing teaching with a client about a new presciption for lithium. Which of the following statements should the nurse include in the teaching?

"We will need to check your lithium levels in the next 3 to 5 days"

A nurse is reinforcing teaching with a client who has galucoma. Which of the following statements should the nurse make?

"Without treatment, glaucoma can cause blindness"

A nurse is reinforcing preoperative teaching with a client who is scheduled for cataract surgery. Which of the following statements should the nurse make?

"You should expect your vision to improve within 2 weeks of the surgery"

A nurse is reviewing the medication administration records of a group of clients who have been newly admitted to a long-term care facility. Which of the following clients should the nurse monitor for EPS?

A client who has schizophrenia and is taking an antipsychotic medication

A charge nurse in an acute care facility receives a client request not to have particular assistive personnel care for her. Which of the following actions should the charge nurse take?

Address the concern with the assigned nurse

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?

Anxiety and diaphoresis

A nurse is caring for a client who has a prescription for schedules opioid analgesia and notes a change the client's in mental status. Which of the following actions should the nurse take? SATA

Apply an ambulation alarm to the client's leg Check on the client hourly

A nurse is collecting data from a school age child who is undergoing a neurological assessment following a head injury. The nurse should document gross incoordination when walking as which of the following findings?

Ataxia

A nurse is collecting data from a client who has meningitis. Which passively flexing the client's neck, the nurse notes an involuntary felxion of both legs. Which of the following conditions is the client displaying?

Brudzinski's sign

A nurse is collecting data from an 8-month-old infant who has increased intracranial pressure (ICP). Which of the following manifestations should the nurse expect?

Bulging fontanel

A nurse ins a long-term care setting is caring for a client who has Alzheimer's disease. The client states, "I just came back from a hard day's work in my office." The nurse should identify this statement is an example of which of the following coping mechanisms?

Confabulation

A nurse is caring for a client who is taking disulfiram and is experiencing severe nausea and vomiting. The nurse should identify that which of the following is the cause for the client's nausea and vomiting?

Consumption of alcohol

A nurse is reviewing the laboratory reports of a client who has bipolar disorder and notes a serum lithium level of 2.0 mEq/L. Which of the following actions should the nurse take?

Determine the client's vital signs

A nurse is reviewing the medical record of a client who attempted suicide. Which of the following findings should the nurse identify as risk factors for suicide?

Diagnosis of major depressive disorder Unemployment Access to firearms

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid?

Disclosure of the treatment is provided Client understands the surgical procedure Voluntary consent is given

A nurse is assisting with the plan of care for a client who has a cerebral aneurysm. The nurse should plan to monitor the client for which of the following early indications of increased intracranial pressure?

Disorientation to time and place

A nurse is preparing a presentation for coworkers about the various herbal remedies clients might report using. Which of the following should she include as an herbal supplement clients might use to help boost their memory?

Ginkgo biloba

A nurse is collecting data from a client who has Meniere's disease. Which of the following is an expected finding for this client?

Gradual hearing loss

A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?

Inability to regulate body temperature

A nurse is contributing the the plan of care for a client who had a craniotomy. Which of the following interventions should the nurse include in the plan?

Maintain seizure precautions

A nurse is caring for a client who ingestd a poison and is now having seizures. Which of the following is the priority action the nurse should take?

Maintain the patency of the client's airway

A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe?

Methadone

A nurse is caring for a client who has a hearing loss in her left ear. Which of the following nursing actions should the nurse take?

Minimize background noise to decrease distractions

A nurse is caring for a client who is scheduled for a Tensilon challenge test to check for myasthenia gravis. Which of the following findings should the nurse identify as a positive result?

Muscle strength becomes temporarily stronger

A nurse is collecting data from an adult client who has meningococcal meningitis. Which of the following findings should the nurse expect?

Petechial rash on the chest and extremities

A nurse is caring for a client who is unconscious and has lost the corneal reflex. Which of the following actions should the nurse take?

Place a patch over the eye

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take?

Place the client in a darkened room

A nurse is assisting with the plan of care for a client who has an intracranial aneurysm. Which of the following interventions should the nurse include?

Place the client in a private room

A nurse is assisting with the care of a newborn who has a myelomeningocele. Which of the following actions by the nurse is appropriate?

Place the newborn in a prone-kneeling positions

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

Plantar flexion of the legs

A nurse is monitoring a post-op client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that client is experiencing pain?

Restlessness grimacing clenching

A nurse is reinforcing preop teaching with a client who is scheduled for retinal detachment repair. Which of the following instructions should the nurse include in the teaching?

Restrict head movement

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

Suction saliva from the client's mouth

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect

The client requires total nursing care

A nurse is at an outpatient surgery center is reinforcing discharge teaching with a client's partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching?

The client should wear dark glasses while outdoors.

A nurse is collecting data from a client who has an acoustic neuroma. Which of the following manifestations should the nurse expect?

Tinnitus

A nurse is assisting with the preparation of an instructional plan for a client who has vision loss. Which of the following strategies should the nurse include in the plan?

Use of auditory or tactile materials

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?

Use the exact same words when repeating statements

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and nausea. Which of the following actions should the nurse take?

Withhold the medication

A nurse is receiving a transfer report for a client who has a head injury. The client has a GC score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

the client opens his eyes when spoken to

A nurse is assisting with monitoring a client who has preeclampsia and is receiving magnesium sulfate. The client's respiratory rate is 8/min. Which of the following should the nurse administer?

Calcium gluconate

A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of the following instructions?

Call the health care clinic to report that the tubes have fallen out

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first?

Check the client's temperature

A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?

Determine the client's perception of his body image

A nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions should the nurse take?

Elevate the head of the bed 30 degrees

A nurse is contributing to the plan of care for a client who is having headaches following the administration of a spinal anesthetic during surgery. Which of the following interventions should the nurse include in the plan of care?

Encourage increased intake of fluids

A nurse is contributing to the plan of care for a client following a lumbar puncture. Which of the following interventions should the nurse include?

Encourage oral fluids

A nurse is caring for a 6-month-old infant who is post operative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

FLACC

A nurse is collecting data from a client who is receiving treatment for alcohol detoxification. Which of the following findings is the nurse's priority?

Hallucinations

A nurse is preparing to administer opthalmic solution to a client. Which of the following actions should the nurse take?

Hold the opthalmic solution 2 cm (3/4 in) above the lower conjunctival sac

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Hypertension

A nurse is caring for a client who has Alzheimer's disease and is confused. Which of the following actions should the nurse take?

Keep familiar personal items in a client's room

A nurse is on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

Keep the client's bed in the lowest position

n acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. While performing a neurological examination, which of the following findings is the earliest indicator of the client's cerebral status?

LOC

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

Move the child into a side-lying position

A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? SATA

Muscle contractions of the neck Fidgeting behavior Impaired Gait

What are the symptoms of Bell's Palsey? (SATA)

Muscle distortion Pain behind the ear Impaired taste

A nurse is collecting data from a client who has ataxia. Which of the following is appropriate to evaluate the client's ability to safely ambulate?

Perform a Romberg test

A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

Place a pillow under the client's head

nurse is contributing to the plan of care for a client who has dementia. Which of the following actions should the nurse include in the plan of care?

Provide a consistent daily routine

A nurse is reinforcing teaching to the family of a client who has Parkinson's disease. Which of the following instructions should the nurse include?

Provide the client a cane

A nurse is collecting data from a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimuli is within normal limits?

Pushes the painful stimulus away

A nurse is collecting data from a client who reports pain. Which of the following client findings should the nurse consider as the most reliable indicator of pain?

Self-report of pain

A nurse is reinforcing discharge instructions for a client following a laminectomy. Which of the following instructions should the nurse include?

Sit in straight-back chairs

A nurse is collecting data from a client who has Parkinson's disease and is experiencing bradykinesia. WHich of the following findings should the nurse expect?

Slurred speech

A nurse is collecting data from a client who is experience alcohol withdrawal delirium. Which of the following finings should the nurse expect? SATA

Visual hallucinations Paranoid delusions Tremors

A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?

increased anxiety

A nurse is reinforcing teaching with a client who has chronic open angle glaucoma. The client has been prescribed pilocarpine ophthalmic solution. Which of the following statements by the client demonstrates an understanding the of the teaching?

"I should expect to have blurred vision for up to two hours after using this medication"

A nurse is reinforcing discharge teaching with a client who is postop following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching?

"I will bend at my knees if I need to pick something up off the floor"

When administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following responses should the nurse make?

"This opens the ear canal, allowing medication to reach the inner ear region"

A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching?

"This test will measure the intraocular pressure of the eye"

A nurse is planning care for several clients and is considering the client's risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?

A client who has chronic atrial fibrillation

A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions?

A sensory warning that a seizure is imminent

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Administer antibiotics when available

A nurse is reinforcing teaching with a client how to use meditation and progressive relaxation techniques to manage stress. Which of the following physiologic outcomes should the nurse instruct the client to expect?

Arousal reduction Decreased BP Decreased HR

A nurse is an urgent care center is collecting data from a client who reports taking an excessive amount of aspirin. Which of the following findings should the nurse identify as an indication of salicylism?

tinnitus

A nurse is caring for an adolesent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the adolescent's parent is the priority for the nurse to address?

"He seems to be getting a lot more bumps and bruises lately"

A nurse is assisting with teaching a group of clients about monitoring for diabetic peripheral neuropathy. Which of the following client statements indicates understanding of this information?

"I might lose awareness of when I'm stepping on a harmful object"

A nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction from the left eye with placement of an intraocular lens implant. Which of the following statements by the client indicates a need for further teaching?

"I will change my eye patch dressing is every other day"

A nurse is caring for a client who has aphasia following a stroke. A family memeber asks the nurse how she should communicate with the client. Which of the following is an appropriate response by the nurse

"Incorporate nonverbal cues in the conversation"

A nurse is teaching a newly licensed nurse about ECT. Which of the following statement by the newly licensed nurse indicated understanding?

"Informed consent should be obtained prior to ECT"

A nurse is reinforcing teaching to parents of a toddler about temper tantrums. Which of the following statements should the nurse include in the teaching?

"Temper tantrums are the toddler's attempt to gain control of a situation"

A nurse is caring for a client who has HTN and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?

"The client has a history of HTN"

A nurse is reinforcing teaching with the family of a client who has a new diagnosis of dementia. Which of the following information should the nurse include in the teaching?

"The manifestations of dementia are progressive and irreversible"

A nurse is reinforcing teaching with the family of a client who is in a halo fixation device. Which of the following statements should the nurse make?

"The purpose of this device is to immobilize the cervical spine"

A client is concerned that her newborn has "crossed eyes" which of the following statements is a therapeutic response by the nurse?

"newborns lack the necessary muscle control to regular eye movement"

A home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. Which of the following information should the nurse include in the plan of care?

"rest in semi-fowler's position"

A nurse is collecting data from a client who self adminsters pilocarpine ophthalmic drops. Which of the following findings by the nurse indicates a systemic adverse effect of this medication?

Diarrhea

A nurse is preparing to administer ofloxacin otic drops to an adult client who has otitis externa. Which of the following actions should the nurse take?

Apply gentle pressure with a finger to the tragus of the ear

A nurse is an assisted-living facility is caring for a client who is in early stages of dementia. The client has been oriented to name and place and is usually cooperative. Which of the following nursing actions is appropriate if the client refuses to take morning medications?

Ask the client to express her reasons for refusing the morning medications and document the event

A nurse is modifying the diet of aclient who has Parkinson's disease and a prescription for selegiline, a monamine oxidase inhibitor (MAOI). Which of the following foods should the nurse eliminate from the client's diet?

Cheddar cheese

A nurse is reinforcing teaching with a client who is taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?

Difficulty voiding

A nurse is collecting data from a client who underwent a stressful event and is experiencing a fight-or-flight syndrome. Which of the following findings should the nurse expect as an immediate response in the client?

Decreased gastrointestinal motility

A nurse on a med-surge unit is assisting with the admission of a client who has vision loss. Which of the following actions is the nurse's priority

Describe the environment to the client

A nurse is assisting with the food tray for a client who is partially blind following a left-sided stroke. Which of the following nursing interventions promotes client independence?

Describe to the client the location of the food on the tray

A nurse in the ER is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify the which of the following factors can cause a myasthenic crisis?

Developing a respiratory infection

A nurse is reinforcing teaching about donepezil with the family of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Fainting episodes can occur

A nurse is reinforcing teaching with a client who reports having migraine headaches. The nurse should identify that the client can use which of the following herbal supplements prophylactically to manage migraine headaches/

Feverfew

A nurse in a long-term facility is performing a mental status examination for a newly admitted client who has dementia. Which of the following data should the nurse include?

Grooming Long-term memory Affect

A nurse is collecting data from a client who has severe dementia and a fractured femur due to a fall. Which of the following manifestations should the nurse understand is a physical finding in acute pain?

Increased pulse rate

A nurse is collecting data from a client who has involved in a motor-vehicle crash. Which of the following techniques should the nurse use to test for corneal reflexes?

Lightly touch the eye with a wisp of cotton

A nurse is contributing the plan of care for a client who has dementia. Which of the following interventions is appropriate to include in the plan of care?

Limit the client's choices for daily activities

A nurse is collecting data from a client who has an epidural hematoma. Which of the following manifestations should the nurse epect?

Lucid period followed by a rapid loss of consciousness after the injury occurs

A nurse is providing discharge instructions for a client following outpatient cataract surgery with insertion of an intraocular lens. Which of the following should the nurse include?

Lying on the unaffected side can prevent complications

A nurse is assisting in planning care for a client who has a head injry and is in a halo traction device. Which of the following actions should the nurse recomment for the plan of care?

Monitor the client for elevated temperature

A nurse is caring for a client who has a cerebral aneurysm. Which of the following actions should the nurse take?

Monitor vital signs at least once each hour

A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan?

Provide a suction setup at the bedside Elevate the side rails when in bed Keep an oxygen setup at bedside

A nurse is caring for a client following a lumbar puncture. Which of the following actions should the nurse take?

Provide oral fluids Monitor for nausea Check LOC Check sensation in toes

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first?

Raise the head of the bed

A nurse is reinforcing teaching with a client who is start taking lithium carbonate. Which of the following dietary supplements should the nurse instruct the client to avoid?

St. John's wort

A nurse is reviewing discharge instruction with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?

Repeatedly ask the client questions to check for orientation

a nurse is reinforcing teaching a client who has a new prescription for phenytoin. The nurse should instruct the client to monitor and report which of the following adverse effects of this medication?

Skin rash

A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

Small drops of clear fluid in left ear

A nurse is collecting data from a client who has nacrolepsy. Which of the following manifestations should the nurse expect?

Sudden attacks of sleep Sleep-wake cycle hallucinations

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to provider immediately?

Sudden sleepiness

A nurse is collecting data from a client who has a leaking cerebral aneurysm. Which of the following findings should the nurse expect?

Sudden, severe headache

A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take?

Take the client to the bathroom on a regular schedule

A nurse is collecting data from a client who is postoperative and receiving IV morphine 1 mg ever 10 min via PCA. For which of the following manifestations should the nurse withhold the morphine?

The client's respiratory rate is 9/min

A nurse is reinforcing teaching with a client who has Parkinson's disease. The client tells the nurse that he gets nausea when he takes his prescribed levodopa/carbidopa. Which of the following foods should the nurse recomment the client take with the medication?

UH IDK.

A nurse is collecting data from a client who reports taking several herbal supplements. Which of the following supplements should the nurse tell the client can increase sedation in clients who take CNS depressant medications?

Valerian

A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother" the nurse replies, "you miss your mother" which of the following therapeutic techniques is the nurse using?

Validation

A nurse is reinforcing teaching with a client about manifestations of lithium toxicity. Which of the following manifestations should the nurse include in the teaching?

Vomiting and diarrhea