PNU 133 PrepU Passpoint Neurosensory Disorders
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
An isolation room close to the nurses' station
A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?
Assist the client to a side-lying position on the floor, and protect her with linens.
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
The nurse is assigned to care for a client following a cerebral vascular accident (CVA). The client is experiencing expressive aphasia. Which nursing interventions would assist in client communication? Select all that apply
Face the client when speaking. Encourage client gestures to communicate ideas. Provide directions in short, simple sentences.
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
Ineffective breathing pattern
A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which of the following objectives is appropriate?
Promoting weight-bearing exercises
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority?
Risk for injury related to neurologic deficit
A client was admitted with a brain tumor. Which vital signs would the nurse expect to notice?
T, 99° F (37.2° C); P, 52; R, 12; BP, 176/86
A client is admitted to the facility for investigation of balance and coordination problems, including possible Meniere disease. When reviewing this client's chart, the nurse expects to find which signs and symptoms?
Vertigo, tinnitus, and hearing loss
A nurse instills atropine drops in both eyes of a client undergoing an ophthalmic examination. Which instruction should the nurse reinforce after administering the medication?
Wear dark glasses in bright light because the pupils are dilated.
A client is admitted because of an episode of acute angle-closure glaucoma. Which medication should the nurse expect to administer?
acetazolamide
The nurse is caring for a client with quadriplegia. Which nursing intervention takes priority?
preventing atelectasis
A client at the eye clinic reports difficulty seeing at night. Which nutritional deficiency should the nurse be sure the client is monitored for?
vitamin A
The nurse is preparing to administer carbamazepine oral suspension, 150 mg by mouth. The pharmacy has dispensed carbamazepine suspension 100 mg/5 mL. How many milliliters of carbamazepine should the nurse administer to the client? Record your answer using one decimal place.
7.5
A client is admitted with Meniere disease. Which instruction should the nurse reinforce in client teaching?
Get up slowly, turning the entire body.
A nurse is positioning a client with flaccid left-sided hemiparesis in bed following a cerebral vascular accident (CVA). Which is the nurse's best intervention?
Position the left arm supported on a pillow.
A nurse performs a neurologic data collection on a client reporting headache and dizziness. Which data collection technique helps determine the motor function of cranial nerve VII?
asking the client to frown, smile, and raise the eyebrows
The nurse is working on a surgical floor. The nurse must logroll a client following a:
laminectomy.
The clinic nurse is working with a client with dysuria who is prescribed phenazopyridine. The nurse will reinforce the client to expect urine that is what?
orange
A nurse is caring for a client who had a lumbar laminectomy 2 days ago. Which finding should the nurse report to the health care provider?
urine retention or incontinence
A nurse is educating the parents of a 1-year-old infant with otitis media. Which statement regarding predisposing factors for otitis media would be most accurate for the nurse to make?
"Eustachian tubes are short, wide, and straight and lie in a horizontal plane."
A nurse is caring for a client who suffered a stroke. The family reports that the nurse on the previous shift failed to administer medications properly or maintain client privacy. What is the best action by the nurse?
Inform the charge nurse of the family's concerns.
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
electromyography (EMG).
A client is scheduled for magnetic resonance imaging (MRI) of the head. Which area is essential to check before the procedure? Select all that apply.
metal fillings, prostheses, or a pacemaker history of claustrophobia
The nurse is caring for a client who underwent a stapedectomy. Which position would have the greatest benefit for prevention of complications and promotion of comfort?
on the unaffected side
The nurse is reinforcing education for a client after cataract surgery. Which statement indicates that a client needs additional education?
"I can't wait to pick up my granddaughter."
The nurse is discharging a client from the hospital after a laminectomy. What statement made by the client indicates that further education should be reinforced?
"I can't wait to toss my granddaughter up in the air."
A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction?
"I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens."
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, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, the examination must be brief but will include which nursing intervention?
Evaluation of the corneal reflex response
An otherwise healthy adolescent has meningitis and is receiving IV and oral fluids. The nurse should monitor this teen's fluid balance to decrease the risk of what complication?
cerebral edema
While in the emergency department, a client with C8 quadriplegia develops a blood pressure of 80/44 mm Hg, pulse of 48 beats/minute, and respiratory rate of 18 breaths/minute. The nurse suspects which condition?
neurogenic shock
A client who's receiving phenytoin to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?
10 to 20 mcg/ml
A client with a head injury, whose neck has been stabilized, is admitted to the hospital. In which preferred bed position would the nurse place this client?
30-degree head elevation
What should the nurse do when administering pilocarpine?
Apply pressure on the inner canthus to prevent systemic absorption.
Identifying factors that trigger seizure activity could lead to which alteration in the child's environment or activities of daily living?
Avoid striped wallpaper and ceiling fans.
When contributing to the development of an education session on glaucoma for the community, which statement would the nurse emphasize?
Glaucoma can be painless with loss of peripheral vision.
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
A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do?
Make sure a tonsil suction device is readily available while providing mouth care.
A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The spouse tells the nurse of feeling guilty for letting the accident happen and reports not sleeping well because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?
Risk for caregiver role strain related to increased client care needs
A nurse is using the Glasgow Coma Scale (GCS) to help determine a client's level of consciousness (LOC). Based on a calculated score on the GCS of 10, what conclusion does the nurse draw?
The client has a decreased LOC but is not in a deep coma.
A client with Alzheimer's disease is being treated for injuries from a recent fall and malnutrition. The nurse determines a need to place the client closer to the nurse's station based on which finding?
The client has a tendency to wander.
