prep-u neuro

The nurse receives a physician's order to administer 1,000 mL of intravenous (IV) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.

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Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?

Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks. Explanation: The scarring of the retinal tear needs time to heal completely. Therefore, resumption of activity should be gradual; the client may resume usual activities in 5 to 6 weeks. Successful healing should allow the client to return to a previous level of functioning.

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. Explanation: A cloudy solution indicates that the drug has changed chemically or has become contaminated. Therefore, the nurse first should advise the client to discard the drug. Advising the client to obtain a fresh container of pilocarpine, watching the client or a family member administer the drug, and advising the client to keep the container closed tightly and protected from light are all appropriate actions to take after telling the client to discard the solution.

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Collect the drainage. Explanation: The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.

A client is receiving an I.V. infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output Explanation: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter Explanation: A full bladder can precipitate autonomic dysreflexia. The nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position cannot prevent autonomic dysreflexia.

A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used?

The client experiences spontaneous remissions from time to time. Explanation: Evaluating drug effectiveness is difficult because a high percentage of clients with MS exhibit unpredictable episodes of remission, exacerbation, and steady progress without apparent cause. Clients with MS do not necessarily have increased intolerance to drugs, nor do they endure long periods of exacerbation before the illness responds to a particular drug. Multiple drug use is not what makes evaluation of drug effectiveness difficult.

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 Explanation: Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim should always seek medical care. Eye irrigation isn't considered a stopgap measure.

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 Explanation: Asking a client to speak louder even when tired may aggravate the problem. Asking the client to speak slowly and distinctly and to repeat hard-to-understand words helps the client to communicate effectively.

A client is about to have a tympanoplasty, and asks the nurse what the surgical procedure involves. The nurse begins the conversation by:

assessing the client's understanding of what the health care provider (HCP) has explained. Explanation: The nurse should first assess the client's knowledge base. Working within the framework of the client's knowledge and educational level, the nurse then can describe the procedure and its benefits.

A client is color blind. The nurse understands that this client has a problem with:

cones. Explanation: Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)?

coughing Explanation: Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should

demonstrate eyedrop instillation. Explanation: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma

Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which body system?

gastrointestinal Explanation: The most common toxicities from NSAIDs are gastrointestinal disorders (nausea, epigastric pain, ulcers, bleeding, diarrhea, and constipation). Renal dysfunction, pulmonary complications, and cardiovascular complications from NSAIDs are much less common.

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

sudden, severe hypertension Explanation: With a cervical injury, the client has sympathetic fibers that can be stimulated to fire reflexively. The firing is cut off from brain control and is both reflexive and massive. It classically produces pounding headache and dangerously elevated blood pressure, "goose bumps," and profuse sweating. Bradycardia, paralytic ileus, and hot, dry skin typically occur during spinal shock, not during autonomic dysreflexia.

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?

unequal pupil size Explanation: Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

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

• Contact the health care provider (HCP) if ICP is greater than 15 mm Hg. • Elevate the head of the bed 15 to 20 degrees. • Monitor neurologic status using the Glasgow Coma Scale. Explanation: The nurse should maintain ICP by elevating the head of the bed 15 to 20 degrees and monitoring neurologic status. An ICP greater than 15 mm Hg with 20 to 25 mm Hg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

semi-Folwer's Explanation: A hyphema is the presence of blood in the anterior chamber of the brain. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as penetrating injury from a small bullet or pellet, or indirectly, such as from striking the forehead on the pavement during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

A nurse has received a shift report on four clients. Which client should she assess first?

An older adult returning to the unit after having a carotid endarterectomy Explanation: The nurse should first assess the client returning from a carotid endarterectomy, who requires close monitoring. The client who had a rhizotomy will require pain assessment after the nurse addresses the client returning from surgery. The clients admitted for observation are stable and are lower priorities than the client returning from a carotid endarterectomy

What should a nurse do when administering pilocarpine?

Apply pressure on the inner canthus to prevent systemic absorption. Explanation: When administering pilocarpine, the nurse should apply pressure on the inner canthus to prevent systemic absorption of the drug. Pilocarpine doesn't cause night blindness. The outer canthus doesn't absorb eyedrops, so applying pressure there won't be helpful. Flushing the client's eye with normal saline solution after administering pilocarpine is contraindicated because it will wash the drug out of the eye, rendering treatment ineffective.

What is the priority nursing intervention in the postictal phase of a seizure?

Assess the client's breathing pattern. Explanation: A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

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. Explanation: Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan.

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

Multidisciplinary approach. Explanation: A multidisciplinary approach to pain relief is needed for greatest effectiveness. In addition to the client, the nurse, and the physician, others who may be needed on the team include a social worker, an occupational therapist, a dietitian, and a psychologist or a psychiatrist. Pain relief interventions based on physiologic and psychological principles can be used simultaneously to obtain greater pain relief. Medication administration is only one option for reducing pain.

The nurse evaluates the client's ability to instill eyedrops correctly. The client correctly demonstrates the procedure when the client:

instills the eyedrops into the conjunctival sac. Explanation: Proper technique for instilling eye drops includes instilling the eyedrops in the conjunctival sac. There is no need for the client to blow the nose after eyedrop administration. Proper technique for instilling eyedrops includes being in a supine position. The applicator tip should remain sterile.

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

"I can participate in sexual activity but might not experience orgasm." Explanation: The woman with spinal cord injury can participate in sexual activity but might not experience orgasm. Cessation in the nerve pathway may occur in spinal cord injury, but this does not negate the client's mental and emotional needs to creatively participate with her partner in a sexual relationship and to reach orgasm. An indwelling urinary catheter may be left in place during intercourse and need not be removed because the indwelling urinary catheter is placed in the urethra, which is not the channel used for sexual intercourse. There are no contraindications, such as hypertension, to sexual activity in a woman with spinal cord injury. Sexual intercourse is allowed, and hypertension should be manageable. Because a spinal cord injury does not affect fertility, the client should have access to family planning information so that an unplanned pregnancy can be avoided.

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 health care 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 his condition with you. You'll have to speak to his power of attorney if you'd like information." Explanation: To maintain client privacy, the nurse may not divulge information about the client to his friends. The nurse may, however, explain that she must maintain client privacy and refer the visitors to the power of attorney who may wish to update them about the client's condition. Option 2 doesn't provide a reason as to why the nurse can't provide the visitors with client information. Option 3 is incorrect because client is aphasic and can't provide his friends with information about his condition. Option 4 requires the client to give permission to divulge information about his condition and because the client is aphasic, he is unable to give permission.

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

"Reviewing your losses is a way to help you work through your grief and loss." Explanation: Spinal cord injury represents a physical loss; grief is the normal response to this loss. Working through grief entails reviewing memories and eventually letting go of them. The process may take as long as 2 years. Telling the client to be patient and that adjustment takes time is a clichéd type of response, one that is not empathetic or responsive to the client's needs. Telling the client to focus on today does not allow time for the grief process, which is necessary for the client to work through and adjust to the loss. The client is not escaping but is reminiscing on what is lost, to work through the grieving process.

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." Explanation: A client taking phenytoin to control seizures must undergo routine blood testing to monitor for therapeutic serum phenytoin levels. Typically, the client takes the medication for 1 year after the original seizure, then is reevaluated for continued therapy. During phenytoin therapy, the client may drive and operate machinery. This drug may cause a decreased heart rate and hypotension.

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:

level of consciousness. Explanation: The level of consciousness (LOC) is the best indicator of brain function. If the child's condition deteriorates, the nurse would notice changes in LOC before any other changes and should notify the health care provider (HCP) that these changes are occurring. Changes in vital signs and pupils typically follow changes in LOC. Motor strength is primarily assessed as a voluntary function. With changes in levels of consciousness, there may be motor changes.

A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately?

new onset of foot drop Explanation: Neurologic symptoms, such as footdrop, or bowel or bladder changes, should be reported to the HCP immediately. When musculoskeletal strain causes back pain, these symptoms may take 4 to 6 weeks to resolve. As an accompanying symptom of acute low back pain, the client may have a diffuse, aching sensation in the L4 to L5 area, pain in the lower back when the leg is lifted, or pain that radiates to the hip. (

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

Ask the staffing coordinator to assign a nursing assistant to sit with the client. Explanation: The nurse should ask the staffing coordinator to assign a nursing assistant to sit with the client. This action promotes client safety while avoiding restraint use. Applying wrist restraints doesn't prevent injury to the lower leg. Also, restraints should be applied only after other less restrictive measures have been attempted. A client with stage II Alzheimer's disease has memory impairment that impedes his ability to remember repeated instruction. Sedation isn't indicated for this client.

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. Explanation: To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which of the following 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. Explanation: Increasing fluid intake will provide an internal irrigation and dilute the urine. This will lessen the probability of renal calculi forming. Cranberry juice is helpful in acidifying the urine and lessening the incidence of cystitis. Ingesting large amounts of milk and vitamin D will not decrease incidence of a UTI or renal calculi. Foods containing vitamins will not necessarily prevent these problems, nor will less acidic urine.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities

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

Prevent an increase in intraocular pressure. Explanation: After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal. Control of pain with analgesics is a secondary goal. The client should avoid getting soap and water in the eye when bathing. Maintaining a darkened environment is not necessary for this client.

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?

Risk for injury related to vertigo Explanation: Vertigo, the chief finding in Ménière's disease, is a severe, rotational whirling sensation that typically causes the client to fall when attempting to stand or walk. Because client safety is paramount, the nursing diagnosis of Risk for injury related to vertigo takes priority. Vertigo doesn't cause pain. Although nausea and vomiting may lead to inadequate nutrition and fluid loss, these problems are secondary to client safety.

A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?

head of the bed elevated to 30 degrees with the client's head in a neutral position Explanation: The head of the bed should be elevated 30 degrees to promote venous drainage and decrease intracranial pressure. The client's head should be in a midline, or neutral, position. Clients with supratentorial surgery should be positioned on the nonoperative side to prevent displacement of the cranial contents by gravity.

The nurse is administering eyedrops to a client with glaucoma. Which is a correct technique for instilling the eyedrops? The eyedrops are placed:

in the lower conjunctival sac. Explanation: Eyedrops are correctly instilled by placing them in the lower conjunctival sac. Eyedrops should not be placed near the lacrimal ducts, to decrease the chance of the medication's being systemically absorbed. Placing the drops on the cornea or sclera is uncomfortable for the client and may cause the medication to run out of the eye socket instead of being absorbed

A nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy. Explanation: The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery

A nurse is caring for a client who's had surgery to repair a hip fracture. The client says his left hand and arm are numb and he can't move the extremity. The nurse contacts the physician, who suspects brachioplexus nerve damage. What additional priority assessment does the nurse need?

Function of the client's left hand before the operation Explanation: Functioning of the affected limb before surgery is the priority assessment information the nurse needs to determine the level of change in the client. She doesn't need to assess function of the right hand or arm because the client has no problem with them. Copies of the operating room notes may indicate positioning but may not be useful in further diagnosis. X-ray won't reveal damage to the brachioplexus nerve.

A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do?

Notify the health care provider (HCP) of the client's breathing pattern. Explanation: Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the HCP immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen, and the depth of breathing is assisted by the ventilator. The HCP will determine changes in the ventilator settings

The nurse is completing a neurologic assessment on a client who has been admitted with a contusion to the brain. Which of the following findings would warrant further action?

Pupils are equal and sluggish in reaction to light. Explanation: Assessing the pupillary response is an important consideration in neurologic assessment. When pupils are sluggish to respond, this indicates neurologic impairment. The Glasgow Coma Scale is used to assess the extent of neurologic impairment. Each of the other findings indicates a normal response to stimuli. Vital signs are normal.

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?

Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. Explanation: Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis