Nuero Test

The nurse helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure?

"For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back."

The nurse is caring for a toddler who is scheduled to have myringotomy tubes placed. Which statement by the child's parents indicates a lack of understanding?

"Hearing loss after the tubes are placed may be permanent."

The parents of a toddler have just learned that their child has profound hearing loss. The parents are very upset and state to the nurse, "It just isn't fair. We did everything right during our pregnancy all the way to this point." How should the nurse respond?

"I can't imagine how difficult this must be. When you're ready I would be happy to arrange a meeting with a support group of other parents with children who have hearing loss."

Gabapentin has been prescribed for a pediatric client. Which statement by the client indicates an understanding of teaching related to the medication?

"I can't take this medication within 2 hours of taking my antacid medication."

A child has been diagnosed with bacterial conjunctivitis. Which statement(s) by the child's parent indicates the need for further education? Select all that apply.

"I will continue to use eye drops until the redness is gone." "Our child can go back to school in 4 hours, after that thick yellow drainage is gone."

A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse?

"The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures."

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The parent questions pain medication for home. Which response by the nurse is most appropriate?

"Your child has a mild concussion; acetaminophen can be given."

The nurse is teaching a group of parents about eyes and eye concerns. The nurse tells these caregivers about a condition that occurs when unequal curvatures in the cornea bend the light rays in different directions and this causes images to be blurred. The condition the nurse is referring to is:

Astigmatism

Antibiotic therapy to treat meningitis should be instituted immediately after which event?

Collection of cerebrospinal fluid (CSF) and blood for culture

The nurse is preparing a care plan for the school-age child with a congenital hearing loss of 60 to 80 dB. Which nursing diagnoses should the nurse include on the care plan for this child? Select all that apply.

Delayed growth and development Impaired verbal communication Risk for injury

In children with otitis media, a procedure known as a myringotomy may be performed. Which statement is most accurate regarding this procedure?

During this procedure, small tubes are inserted into the tympanic membrane.

A 1-year-old female has been diagnosed with her fourth ear infection since birth. The nurse understands that children are more susceptible to ear infections than adults because of which anatomical difference?

Infants have horizontally placed Eustachian tubes.

A nurse is assessing a child's vision. Which test should the nurse use to test for accommodation?

Moving a penlight toward the client's nose and observing whethe eyes can follow it

A child was just brought into the emergency department after falling off a skateboard. The parents report that their child lost consciousness briefly and they noticed watery drainage coming from the nose. What action should the nurse take first?

Notify the emergency department health care provider of the information the parents reported.

The nurse is caring for a preschooler who has developed a high fever and has just had a seizure. What is the best action by the nurse?

Remove any blankets or heavy clothing and replace with a thin sheet

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care?

Risk for injury related to seizure activity

A group of students are reviewing the various causes of bacterial conjunctivitis in children. The students demonstrate understanding of this condition when they identify what as the most common cause?

Staphylococcus aureus

The school nurse is instructing the classroom teacher regarding a student newly diagnosed with amblyopia. To prepare for classroom instruction, which concept is most important for the nurse to convey to the teacher?

Student placement in the room is important but all other teaching methods may remain the same.

The nurse is discussing the ears and hearing in a child with a group of peers. Which statement is most accurate related to this topic?

The eustachian tube in the infant is straighter and wider than in the adult.

An adolescent is brought to the ambulatory care clinic after being hit in the eye during a sporting event. There is no serious damage but the adolescent has a "simple contusion" and scleral hemorrhage. What information should be provided?

The facial bruising should clear up in about 3 weeks.

When assessing the client with Parkinson's disease, the nurse should observe the client for:

a stiff, masklike facial expression

A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which area that is a potential pressure point when the client is in a side-lying position?

ankles

A client recovering from Guillain Barré syndrome states, "I'm nervous that this disease will come back." Which nursing diagnoses is most suggested by this comment?

anxiety

A group of nursing students are reviewing cerebral vascular disorders and risk factors in children. The students demonstrate understanding of the material when they identify which as a risk factor for hemorrhagic stroke?

arteriovenous malformations (AVMs)

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

ease the client to the floor maintain a patent airway obtain vital signs record the seizure activity observed

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an I.V. injection of a medication. What is the medication the nurse tells the client they'll receive during this test?

edrophonium

A 1-year-old comes to the clinic for a routine visit. The eye examination reveals an enlarged, edematous, and hazy cornea. The child appears sensitive to light. What should the nurse suspect

infantile glaucoma

A 1-year-old comes to the clinic for a routine visit. The eye examination reveals an enlarged, edematous, and hazy cornea. The child appears sensitive to light. What should the nurse suspect?

infantile glaucoma

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?

infection

corneal abrasion

photophobia, ocular pain, subconjunctival hemorrhage

After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eye drops. What is the expected outcome of applying pressure? Pressure:

prevents the medication from entering the tear duct

anaphylactic shock

pruritus, hypotension, laryngeal edema

When caring for a client with myasthenia gravis, the nurse should assess the client for which manifestations of cholinergic crisis? Select all that apply.

ptosis fasciculation respiratory rate of 6 breaths/min and irregular rhythm

The nurse is developing a plan of care for this client who has undergone a craniotomy. Which complication is this client at risk for developing in the postoperative period? Select all that apply.

seizures, cerebral edema, intracerebral hematoma

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?

the client's ICP remains elevated

The client asks when to stop taking the eye medication for chronic open-angle glaucoma. The nurse should tell the client:

to use the eye medication for the rest of life

SIADH

concentrated urine, reduced urine output

The nurse is educating the parents of a 4-year-old boy with strabismus. Teaching for the parents would include the:

importance of patching as prescribed.

The mother of a newborn with a caput succedaneum asks the nurse how this happened to her baby. Which response by the nurse would be most appropriate?

"During delivery, your vaginal wall put pressure on the baby's head."

A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?

positive kernig sign

A 13-year-old reports she recently saw a television program showing surgery to correct vision problems. She states she hates wearing glasses and wants to have this procedure done. What is the best response by the nurse?

"Although there are surgeries for vision, they are not normally recommended for someone your age."

The school age child has been diagnosed with astigmatism. The parents state, "I never knew our child had trouble seeing at a distance." How should the nurse respond?

"Astigmatism does not mean being nearsighted. It is actually a curvature of the cornea that causes blurry vision."

A child diagnosed with acute otitis media has been given a prescription for benzocaine. The nurse is correct when she makes which statement?

"Benzocaine drops should be placed in your ear to numb it and reduce pain."

A nursing instructor is teaching about eye disorders in childhood. Which statement made by a student indicates a need for further instruction?

"Cataracts are only present in adults."

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question?

"Did you use any medications, like aspirin, for the fever?"

The school nurse is educating the parents of a child with infectious conjunctivitis. Which comment provides the most value for prevention?

"Don't use anything that touches her face."

Upon assessment of an infant the nurse suspects the child has positional plagiocephaly. What questions should the nurse ask the parents to help confirm if this is correct?

"How much tummy time do you plan each day for your infant?" "Besides transporting your infant in the car, how much time do you place your infant in the car seat every day?" "Do you follow the recommended guidelines of placing your infant on the back to sleep rather than the abdomen?"

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the father would indicate to the nurse that additional teaching should be done?

"I always keep phenobarbital with me in case of a fever."

The nurse is preparing a toddler for surgery for insertion of pressure-equalizing (PE) tubes. The nurse is ensuring the parents understand the procedure. Which comments by the parents demonstrate to the nurse that they understand the procedure? Select all that apply.

"I am excited to see if our child starts talking more after the tubes are placed." "We live on a lake and often swim with our child. We will be sure to use earplugs when swimming." "Our surgeon may require the use of earplugs when bathing our child."

The nurse has finished teaching the mother of a 5-year-old male diagnosed with bacterial conjunctivitis how to manage her son's infection at home. Which statement by the mother would indicate a need for further education?

"I will use Visine drops in his infected eye to help reduce redness."

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 can't I 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 is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status?

"She has been irritable for the last hour....seems like she is just upset for some reason."

The parents of a child with a history of seizures who has been taking phenytoin ask the nurse why it's difficult to maintain therapeutic plasma levels of this medication. Which statement by the nurse would be most accurate?

"Small increments in dosage lead to sharp increases in plasma drug levels."

The parent of a 12-year-old child with Reye syndrome approaches the nurse wanting to know how this happened to the child, saying, "I never give my children aspirin!" What could the nurse say to begin educating the parent?

"Sometimes it is hard to tell what products may contain aspirin."

The mother of a 10-day-old infant reports her baby has been having "lots of eye discharge." What is the best initial response by the nurse?

"Tell me more about this drainage."

The nurse is educating the parents of a 7-year-old boy who has hearing loss due to otitis media with effusion. Which statement by the parents indicates that further education is needed?

"We need to raise the volume of our voices significantly so he can hear us."

The nurse is teaching new parents about cephalohematoma. Which statement by the parents suggests the need for further teaching?

"We should expect to see some discoloration on our child's scalp."

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 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.

The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse?

Administer lorazepam IV as prescribed.

A registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel are caring for a group of clients. The RN asks the assistive personnel to check the pulse oximetry level of a client who underwent a laminectomy. The assistive personnel reports that the pulse oximetry reading is 89% on room air. The client has a prescription for oxygen at 2 L/min for a pulse oximetry level below 92%. The RN is currently assessing a postoperative client who just returned from the postanesthesia care unit. How will the RN proceed?

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

Following a transsphenoidal hypophysectomy, the nurse should assess the client for which sign of a potential complication?

CSF leak

The nurse is caring for a 7-year-old child in an outpatient clinic. The child is diagnosed with amblyopia that is unrelated to other disorders. Which intervention should be most helpful at this time?

Educating parents on how to use prescribed atropine drops.

The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP?

HTN

The nurse is caring for a child who has suffered a head injury and has had an ICP monitor placed. Which prescription by the health care provider would the nurse question?

Initiate an IV of 0.9% NS to run at 250 ml/hr.

An 8-year-old boy comes to the emergency room with an eye injury after having a glass bottle shatter near his face. Which intervention should the nurse do first while assisting this client?

Instill a few drops of a topical anesthetic into the affected eye

A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially?

Institute droplet precautions in addition to standard precautions.

A nursing student is doing a clinical rotation on a pediatric floor and is learning about normal growth and development. What can impact normal growth and development? Select all that appl

Interference with vision Interference with hearing

Absence seizures are marked by what clinical manifestation?

Loss of motor activity accompanied by a blank stare

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure?

Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention

A 4-month-old infant is seen at the ambulatory care clinic and diagnosed with nasolacrimal duct obstruction. The mother asks what can be done. What information should be included in the information provided to the parent?

Most of these conditions will spontaneously resolve.

The pediatric office nurse notes that several of the young children that are waiting to see the physician may have conjunctivitis. Which findings are consistent with bacterial conjunctivitis? Select all that apply.

Only the right eye is involved. The drainage is yellow and thick.

A nurse demonstrates understanding of the various levels of consciousness as they progress from most alert to least alert. Place the levels of consciousness in the order that reflects this progression.

Oriented to person, place, and time Disorientation Obtundation Stupor Coma

The nurse is planning an education program on ear infections in children. What information should be included? Select all that apply.

Otitis media occurs more in the winter months. Otitis media is most common in male children.

A nurse is caring for a newborn with anencephaly. Which intervention will the nurse use?

Place a cap or similar covering on the newborn's head.

A child diagnosed with conjunctivitis is being seen in the pediatric clinic. Which statements are correct regarding conjunctivitis? Select all that apply.

Purulent drainage is a common symptom. It is highly contagious. Warm compresses are used to remove crusts that form on the eyes.

The nurse is taking a health history for a 9-year-old child with conjunctivitis. Which finding would suggest that this is allergic conjunctivitis?

Recently helped clean the basement

The nurse is assessing a child with an eye problem. Which symptom, if present, would rule out a hordeolum?

Reddened conjunctiva

A client who has apnea during sleep would require which of the following interventions? Select all that apply.

Refer to primary healthcare provider Assess sleep routine/hours Have client keep a sleep diary

A 5-year-old child is diagnosed with acute otitis media. Which nursing intervention would be priority?

Relieving the child's pain

When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply.

The nurse has oxygen available to use during a seizure. The nurse teaches the caregivers regarding seizure precautions. The nurse positions the child on the side during a seizure. The nurse stays with the child and calls for help when a seizure begins. The nurse pads the crib or side rails before a seizure.

The nurse is caring for a client with a diagnosis of cerebrovascular accident (CVA) with left-sided hemiparesis. What would be important nursing measures in the acute phase of care? Select all that apply.

Turn and position every 2 hours. Perform passive range of motion on the affected side. Support the affected side with pillows.

The nurse is educating the parents of a 7-year-old girl with epilepsy about managing treatment of the disorder at home. Which intervention is most effective for eliminating breakthrough seizures?

Understanding the side effects of medication

The nurse is preparing a child experiencing new-onset seizures for an electroencephalogram (EEG) test. How can the nurse best explain this procedure to the child?

Use a doll with electrodes attached to the head.

One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do?

Use sunglasses that wrap around the side of the face when in bright light.

A 10-year-old client has just been treated for external otitis (acute otitis externa or swimmer's ear) and now the nurse is teaching the boy and his parents about prevention. Which recommendation should the nurse include?

Using a hair dryer on cool to dry the ears.

The nurse is assessing a toddler for motor function. Which activity will be the most valuable?

Watch the child reach for a toy.

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)?

While assessing the child's pupils, there is no change in diameter in response to a light.

A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?

You're in the hospital. You were in an accident and unconscious.

The community health nurse is preparing a presentation on safety measures to prevent injuries in children. Which example of proper safety guidelines should the nurse include? Select all that apply.

a child wearing a helmet while ice skating an infant in a car seat a child wearing a helmet, knee pads, and elbow pads while riding a skateboard

The nurse should inform a client with Ménière's disease that before an attack of the disease, the client may experience:

a feeling of inner ear fullness

The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which foods/fluids for breakfast?

a full breakfast as desired without coffee, tea, or energy drinks

The nurse is caring for a near-term pregnant woman who has not taken prenatal vitamins or folic acid supplements. Which congenital defect is most likely to occur based on the mother's prenatal history?

a neural tube defect

A 9-year-old client who suffered a head injury has strabismus. The nurse assesses the client for intracranial pressure (ICP). Which additional intervention is most important for the nurse to perform?

assess LOC

Indicated for maintaining ICP

administer a corticosteriod, monitor nuerologic statis

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

The nurse is caring for a 20-month-old girl with equivocal bacterial otitis media, a severe earache, and a temperature of 39°C (102.2°F). Which intervention would the nurse expect to implement?

administering antibiotics as soon as they're available

A new nurse has been assigned to the neurologic intensive care unit. Which client would be best to assign the nurse? A client:

admitted 48 hours ago with bacterial meningitis who requires antibiotic administration

The nurse is assessing a client for potential subdural hematoma development after a head injury. Which manifestation does the nurse anticipate seeing first?

alteration in LOC

The nurse is screening a 4-year-old girl for vision problems. What problem could result in loss of vision?

amblyopia

When teaching a parent about amblyopia, it would be most important to explain that:

amblyopia is correctable if the child is properly treated before 6 years of age.

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

assume a reclining or flat position

To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority?

cerebral edema

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

check the equipment

An auto mechanic accidentally has battery acid splashed in their eyes. The coworkers irrigate the eyes with water for 20 minutes, then take the mechanic to the emergency department of a nearby hospital, where the mechanic receives emergency care for corneal injury. The physician orders dexamethasone, two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate, 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. The nurse knows that dexamethasone exerts its therapeutic effect by

decreasing leukocyte infiltration at the site of ocular inflammation.

A client has chronic open-angle glaucoma. What should the nurse ask the client about when conducting a focused assessment?

decreasing peripheral vision

When a client is recovering as expected from spinal anesthesia, the nurse should assess:

degree of response to pinpricks in the legs and toes

A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when

documenting medications after administation

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to do what?

escape the source of pain

A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin to control seizures, the nurse assesses for

excessive gum tissue growth

The nurse is assessing a client's motor response after brain surgery. The nurse pinches the client's skin to elicit a response and observes the client's arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response?

extension posturing

The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply.

eye opening verbal response motor response

The nurse assesses an infant diagnosed with bacterial meningitis. The nurse should ask the parent if the infant has which symptoms? Select all that apply.

fever vomiting poor feeding

Atropine sulfate is contraindicated as a preoperative medication for which client? A client with:

glaucoma

A nurse is caring for a client with Alzheimer disease who was admitted to the hospital from a nursing home. The hospital staff is having difficulty managing the client's urinary incontinence because the client wanders around the unit all day. What is the most appropriate action by the nurse to assist with elimination?

incorporate a toileting schedule into the pattern of the client's wandering

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis?

ineffective airway clearance

The nurse is preparing an in-service for the staff about abusive head trauma (shaken baby syndrome). When planning to review risk factors, what should be included? Select all that apply.

infant with colic financial concerns in the family. premature infants teen parents

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?

isolation room 3 doors down from nurses' station

A child returns to the clinic after an episode of external otitis (acute otitis externa or swimmer's ear) that has resolved. What would the nurse emphasize as the priority for preventing future episodes?

keeping ear canals dry

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate?

limiting fluid intake to 1L per day

The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease?

low sodium

The nurse is carrying out the plan of care for this client after the craniotomy. Which action(s) should the nurse take? Select all that apply.

maintain HOB at 30 degrees pad the side rails of the bed monitor LOC administer dexamethasone

The primary nursing goal for a client with myasthenia gravis is to:

maintain resp function

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which condition?

meningitis

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

monitor urine output

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?

moving the infant's head every 2 hours

A nurse is monitoring a client for adverse reactions to dantrolene. Which adverse reaction is most common?

muscle weakness

What assessment findings would the nurse expect in a client with progressive myasthenia gravis?

muscle weakness, difficulty swallowing, double vision, and difficulty speaking.

The vision impairment in which the child can see objects at close range but not at a distance is known as:

myopia

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. What should the nurse do next?

notify the HCP

The nurse is assessing a child following a head injury sustained in a bicycle accident. The child falls asleep frequently unless the parents are talking to the child or the nurse is asking the child questions. How should the nurse document the child's level of consciousness?

obtunded

The nurse administered dexamethasone at 1315, per the neurosurgeon's prescription. On the 1400 assessment, which finding indicates an effective outcome? Select all that apply.

orientation, ICP, vital signs

A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply.

oxygen gauge and tubing suction at bedside padding for side rails

Following nasal surgery, the client has packing in the nose. The nurse should:

perform frequent mouth care

uveitis

photophobia, ocular pain

Which nursing action addresses the primary concern for a client with Guillain-Barré syndrome?

prepare for mechanical vent

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

prevent an increase of ICP

The nurse is educating the parents of a 6-year-old child about preventing hearing loss. Which topic will be included in the discussion?

prevention and treatment of otitis media

The nurse observes a visitor having a tonic-clonic seizure on the floor in the hallway of the acute care floor. What is the nurse's appropriate intervention when caring for the visitor?

protecting the visitor's head with a pad to prevent injury

A nurse is reviewing the results of a lumbar puncture of a child. The nurse identifies which results as being abnormal? Select all that apply.

specific gravity of 1.011 cloudy in color granulocytes are present

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

stay with the client and encourage them to eat

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for:

sudden, severe hypertension

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to

support the joint where the tendon is being tested

A child has recently been diagnosed with cataracts. The treatment for cataracts is:

surgery

acidic ocular burns

swollen eyelids, ocular pain, subjunctival hemorrhage, marbleized cornea

When assessing a neonate for seizures, what would the nurse expect to find? Select all that apply.

tachycardia elevated blood pressure jitteriness ocular deviation

A nursing goal immediately following surgery for a client who has had a cataract removed is:

the client describes methods to prevent an increase in intraocular pressure.

After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior?

the client has developed tolerance to the dose of morphine

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean them from sedation therapy. A nurse needs further assessment data to determine whether

the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

the paralysis caused by this disease is usually temporary

An 8-year-old child is diagnosed as having tonic-clonic seizures. The nurse would want to teach the parents that:

their child should maintain an active lifestyle

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?

to prevent vision loss

The nurse is to check a client's gag reflex. The most effective technique for testing the gag reflex is to:

touch the back of the client's throat with a tongue blade

The nurse is caring for an 8-year-old girl who was in a car accident. Which symptom suggests the child has a cerebral contusion?

trouble focusing when reading

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?

using a picture board for the client to point to pictures

The nurse is caring for a 3-year-old boy who is experiencing seizure activity. Which diagnostic test will determine the seizure area in the brain?

video electroencephalogram

A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find?

vision changes

The nurse is educating the parents of a 4-year-old boy who has been diagnosed with amblyopia ("lazy eye"). Which comment provides information most helpful for the parents to know?

"Give him a prize when he wears the patch."

A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse?

"This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome."

The nurse provides education to the parent of an infant being treated for hydrocephalus with a ventriculoperitoneal (VP) shunt. Which statement by the parent indicates the need for further instruction?

"This shunt is the only surgery my baby will need."

The parents of an 8-year-old child report that the child's teachers noted the child is having problems seeing the board in school but state they do not understand this since the child is able to read from the computer with no difficulty. Which response from the nurse is most appropriate?

"What you are describing may be what is called myopia."

The nurse is assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III?

A bright-colored toy is moved in the child's visual fields.

The nurse is preparing a nursing care plan for a 2-year-old child with hearing impairment. Which intervention will be part of the plan?

Assess the child's ability to convey information.

The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority?

Assess the client's respiratory status.

The client with a cervical spinal cord injury is admitted to the rehabilitation unit with skeletal traction (Gardner-Wells Traction). What nursing actions are a priority when caring for the client? Select all that apply.

Assess the client's skin integrity. Maintain proper body alignment. Assess client's neurological function.

The nurse is caring for a 24-month-old boy with regressed retinopathy of prematurity. Which intervention is priority for this child?

Assessing the child for asymmetric corneal light reflex.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.

Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place.

The mother of an infant reports that her child is frequently choking when breastfeeding or taking a bottle. The nurse plans on assessing which cranial nerve when addressing the mother's concerns?

IX

A parent calls the nurse triage line to say the child accidentally got hit in the eye and the parent believes the child will have a black eye. Which instruction is important for the nurse to provide this parent?

Place ice on the eye for 20 minutes/off the eye for 20 minutes for 24 hours.

When communicating with a client who has aphasia, which approaches are helpful? Select all that apply.

Present one thought at a time. Speak with normal volume. Make use of gestures. Encourage pointing to the needed object.

The nurse is caring for a 6-month-old infant diagnosed with otitis media. Which clinical manifestation would likely have been noted in this child?

Shaking the head and pulling the ear

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for

hypoxia

The nurse is caring for a child who has had persistent otitis media effusions and is scheduled to have pressure equalizing tubes placed in 3 days. What should the parents observe after the tubes have been placed?

improvement of the child's language and speech development

Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem?

intracranial hemorrhaging

The nurse is caring for an infant with increased intracranial pressure. The mother is preparing to feed the child. What action by the mother indicates an understanding of the proper care of this infant?

placing the infant in an infant car seat after feeding the infant

Nuerogenic diabetes insipidus

polyuria, polydipsia

The nurse is caring for a client who had a cerebrovascular accident (CVA) and needs to be fed. What instruction would the RN give the unlicensed assistive personnel (UAP), who will feed the client?

position the client in a sitting position before feeding

Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n):

steroid

An infant is brought to the emergency department after falling off the parents' bed and hitting the head. The infant is diagnosed with a concussion and is safe to return home. Which instruction(s) does the nurse provide the parents for home care of this infant? Select all that apply.

"Have someone in the home with your infant for the next 24 hours." "Return to the emergency department if your infant vomits more than 2 times." "Return to the emergency department if you notice your infant's pupils are different sizes."

The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education?

"I hate to think that I will need to be worried about my child having seizures for the rest of his life."

The parent of a child having tympanoplasty tubes placed asks, "Will my child lose hearing while the tubes are in place?" What is the nurse's best answer?

"The tubes are inserted into a section of eardrum in which the hearing is not affected."

A client with a head injury is being monitored for increased intracranial pressure (ICP). The client's blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore their cerebral perfusion pressure (CPP) is

52

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure and monitors the blood pressure for signs of widening pulse pressure. The client's current blood pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole number.

90

An infant is born with congenital glaucoma. The infant is scheduled for surgery to relieve this condition at age 2 days. Which prescription should the nurse question for the infant?

A preoperative injection of atropine

The nurse is teaching parents of a 6-year-old child about otitis media (OM). What predisposes the child to OM infections?

Bacteria entering through the eustachian tube

The nurse has received orders from the primary health care provider (HCP). Which action should the nurse perform immediately? Select all that apply.

Begin an intravenous infusion of epinephrine, and titrate to mean arterial pressure. Keep a cervical collar in place. Provide emotional support to the client and family. Begin an intravenous infusion of 0.9% normal saline.

The ED team makes a diagnosis of neurogenic shock. Which complication is this client at risk for developing? Select all that apply.

DVT autonomic dysreflexia PE pressure ulcers

The nurse is assigned an infant with a possible neurological disorder. Which assessment finding would the nurse communicate to the health care provider as a late sign of increased intracranial pressure?

Decorticate posturing and fixed and dilated pupils

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan?

Decrease environmental stimulation

A child is being prepared for discharge after sustaining a simple contusion of the eye. Which advice would the nurse expect to include in the discharge instructions?

Encourage the parents to apply ice to the area for 20 minutes at a time for the first 24 hours.

A client is discharged to home following hospitalization for percutaneous endoscopic gastrostomy tube placement to assist with nutrition. The client's primary diagnosis is amyotrophic lateral sclerosis (ALS). The client can transfer from the bed to a chair but can't walk. The client and their family are concerned about the client's ability to maintain mobility at the highest possible level following a surgical procedure. The nursing diagnosis most appropriate for this client is

Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate.

What is a true statement regarding status epilepticus?

It is a common neurologic emergency in children.

The nurse is caring for a child who has conductive hearing loss. What is true regarding this type of hearing loss?

It is caused by chronic otitis media or another infection.

A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that best indicator of the child's brain function is which factor?

LOC

In examining the vision of a 9-year-old girl, the nurse notices that she frequently reaches either too far or not far enough when attempting to take an object from the nurse's hand. Which condition does the nurse suspect?

Lack of depth perception (stereopsis)

A young child in the clinic reports pain and has redness on the lid of the right eye. Upon further examination, the nurse notices swelling in the preauricular lymph node along with tenderness. What should the nurse suspect?

Stye

A 9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate?

Teach the child and his parents to keep a headache diary.

The nurse is providing education to the parents of a female toddler with hydrocephalus who has just had a shunt placed. Which statement is the best to make during a teaching session

Tell me your concerns about your child's shunt.

The nurse is performing a physical assessment for an 8-year-old child with an earache. Which sign or symptom indicates external otitis (acute otitis externa or swimmer's ear)?

The child cries out when the ear is grasped

The nurse is interviewing the caregivers of a child brought to the emergency unit. The caregiver states, "She has a history of seizures but this time it lasted more than 30 minutes and she just keeps having them." The most accurate description of this child's condition would be:

The child is in status epilepticus.

During the trial period to determine the efficacy of an anticonvulsant drug, which caution should be explained to the parents?

The child shouldn't participate in activities that could be hazardous if a seizure occurs

A school-aged child with seizures is prescribed phenytoin sodium, 75 mg four times per day. What instruction would the nurse give the parents regarding this medication?

The child will have to adhere to good tooth brushing

The nurse is caring for a child who has been diagnosed with acute otitis media three times in the past year. Which factors noted in the medical record would be considered contributing factors to this condition? Select all that apply.

The child's father smokes. The child's older siblings have been diagnosed with acute otitis media in the past. The child shares a bedroom at home with 3 siblings. The family home is occupied by 10 family members.

The nurse develops a teaching plan for a client scheduled for a spinal fusion. What should the nurse tell the client?

The client will typically experience more pain at the donor site than at the fusion site.

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 pressire

A client is about to have a tympanoplasty and asks the nurse what the surgical procedure involves. What should the nurse do first when answering the question?

assess the client's understanding of what the healthcare provider has explained

A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as:

battle sign

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

compliance with the prescibed medication regimen

After cataract removal surgery on the left eye, the client sits up and reports having sharp pain in the operative eye. What should the nurse do next?

contact the HCP

During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed?

dramatic increase in head circumference

The nurse has developed a nursing plan for the care of a 6-year-old girl with congenital hydrocephalus whose shunt has become infected. The most important discharge teaching point for this family is:

ensuring the parents know how to properly give antibiotics.

The nurse is providing immediate postoperative care for a 3-month-old who had a cataract removed. Which intervention would be the priority?

ensuring the protective eye patch is securely in place

The nurse knows that the heads of infants and toddlers are large in proportion to their bodies, placing them at risk for what problem?

head trauma

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

helicopod

spinal shock s/s

hypotension, bradycardia, bowel distension, flaccid muscles

A 10-year-old boy has been experiencing complex partial seizures and has not responded well to medication. Surgery is planned to remove brain tissue at the seizure foci. Which diagnostic test would be the most accurate in identifying the seizure foci?

positron emission tomography

A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority?

risk for injury

A 12-year-old child has been prescribed phenytoin. What information should be included in discussion about this medication?

use a soft toothbrush

The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client?

use of anticonvulsant meds

The nurse is educating the family of a 7-year-old with epilepsy about care and safety for this child. What comment will be most valuable in helping the parent and the child cope?

use this info to teach family and friends

The nurse is educating the parents of a 5-year-old girl with infectious conjunctivitis about the disorder. Which information is most important to provide to prevent the spread of the disorder?

washing hands frequently

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse meets with the team to develop a change strategy based on indicators. Which statement by a team member shows a need for further teaching regarding performance management?

we can discipline the ED staff for not getting the clients to the ICU fast enough

The nurse is providing teaching to the parents of a child recently prescribed carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching?

"I need to watch for any new bruises or bleeding and let my health care provider know about it."

While caring for a child who will be undergoing a lumbar puncture, the nurse explains the procedure to the infant's mother. Which statement by the mother would indicate a need for further education?

"I will cradle her in my arms after the procedure for at least 30 minutes."

A parent of a newborn asks the nurse if there is any way to prevent acute otitis media. What would the nurse state to the parent?

The frequency of otitis media is reduced in breastfed infants.

The nurse is assessing a 5-month-old infant. What would cause the nurse to be concerned about a possible visual impairment?

The infant does not imitate facial expressions.

The nurse caring for a 3-year-old child with a history of seizures observes the child having a seizure. What information should the nurse document concerning the event? Select all that apply.

Time the seizure started Factors present before seizure started Eye position and movement Incontinence of urine or stool

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply.

by calling a code blue, the nurse disregarded the client's advance directives and DNR order The physician was correct to stop resuscitation efforts

The nurse in the emergency department is caring for a child who has a simple contusion of the right eye following a motor vehicle accident. Upon discharge to home, which response by the parents requires further clarification?

"I will need to apply heat to the eye four times a day."

A nurse is educating a client recently diagnosed with early glaucoma. Which client statement indicates further teaching is necessary?

"I will take my latanoprost eye drops as soon as I start to feel pain."

The nurse is obtaining the history from the parents of an infant who is suspected of having infantile glaucoma. Which statement by the parents would help to confirm this suspicion?

"It seems like bright lights really bother him."

The nurse is educating the parents of a premature newborn diagnosed with retinopathy of prematurity. Which comment will be part of the information provided?

"It's an overgrowth of retinal blood vessels."

The caregiver of a 2-year-old child tells the nurse, "They told me my daughter has an eye disorder called hyperopia." Which statement made by the mother indicates she has an understanding of this child's current condition?

"Now I know why when she is working on puzzles she says her eye is sleepy."

The nurse is educating a 13-year-old paintball enthusiast about sports-related injuries. Which comment is most likely to be accepted by the child?

"Play tough, but wear protective gear."

A toddler has been diagnosed with otitis media with effusion. The parents tell the nurse, "We really don't understand what that diagnosis means." How should the nurse respond?

"The diagnosis means unwanted fluid is within the middle ear space, and there may or may not be an infection present."

A 1-year-old infant has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents?

"The surgery was successful. Do you have any questions?"

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. What should the nurse tell the client to do to prepare for this test?

"You will need to hold your head very still during the examination."

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

absence of reflexes along with flaccid extremities

During physical assessment of a 2-year-old child, the nurse becomes concerned that the child may have a cataract in one eye. Which sign or symptom suggests the child has a cataract?

absence of the red reflex

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first?

activate the RRT

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 caring for an adolescent who suffered an injury during a diving accident. During assessment the client is demonstrating the posturing in the figure. The nurse is aware that this type of posturing is the result of injury to what area?

brain stem

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.

collection of the sound waves in the pinna transmission of vibrations through the hammer, anvil, and stirrup stimulation of nerve impulses in the inner ear transmission of vibrations to the auditory area of the cerebral cortex interpretation of sound by the cerebral cortex

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

coughing

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates

cranial nerves IX and X

Sensorineural hearing loss results from which condition?

damage to the cochlear or vestibulocochlear nerve

After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify which condition as a neural tube defect

hydrocephalus

neurogenic shock

hypotension, bradycardia, lack of perspiration

The best method to remove cerumen from a client's ear involves:

irrigating the ear gently

During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take?

report to HCP

The nurse is preparing a care plan for a child who has a seizure disorder. The child experiences tonic-clonic seizures. Which nursing diagnosis will the nurse identify as having the highest priority?

risk for injury

A nurse is caring for an infant who has just undergone a ventricular tap. In what position should the nurse place the infant immediately after the procedure?

semi-Fowler position with a parent at the bedside

A child is brought to the emergency department after experiencing a series of continuous seizures. The nurse is reviewing the orders for care and treatment. Which order would be of the highest priority?

serum glucose level

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

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."

A client with a history of painful, continuous muscle spasms is prescribed diazepam, 2 mg P.O. twice daily. The client states the medication is effective and requests to use it long term. Which response by the nurse is most appropriate?

"Long-term use of this medication may result in addiction."

increased ICP

Bradycardia, widening pulse pressure, increased systolic BP

A client who has Ménière's disease is experiencing an acute attack of vertigo. What should the nurse do to help the client manage the attack?

darken the client's room and provide a quiet environment

The nurse is reviewing the Nurses' Notes of 2100, the Ophthalmic Note of 2105, and the Nurses' Notes of 2300. Which assessment finding(s) indicate that the client's condition has improved? Select all that apply.

particles removed from the conjuctival fornix conjuctival pH of 7.3 pain level of 4 on a 0-10 scale

A client with a ruptured intervertebral disc at L4-L5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. How should the nurse interpret this finding?

postural deformity

The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. What should the nurse do next?

readmister the residual to the client, and continue with the feeding.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin. Client teaching about this drug should include which instruction?

schedule follow-up visits with your physician for blood tests

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to

stick out the tongue and move it rapidly from side to side and in and out.

The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the healthcare provider?

worsening headache

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent?

succinylcholine

Which is not a typical clinical manifestation of multiple sclerosis (MS)?

sudden bursts of energy

Friends come to visit a client admitted with new-onset ischemic stroke. The stroke has caused aphasia and right-sided weakness. The client has an advance directive and an identified healthcare power of attorney. The friends ask the nurse about the client's condition. How should the nurse respond?

"I'm not at liberty to discuss their condition with you. You'll have to speak to the client's power of attorney if you'd like information."

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions?

Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.

The nurse is caring for a client with a subdural hematoma. Which is the priority outcome?

ensure airway patency and optimal oxygen levels and protect from injury

The nurse is performing irrigation to the right eye. Which action(s) should the nurse take? Select all that apply.

irrigate the eye with NS apply the anesthetic eyedrop to the right eye check the conjunctival pH level periodically while irrigating remove any particle with a moistened cotton swab

Which nursing goal is realistic to establish with a client who has multiple sclerosis (MS)?

improved muscle strength