PREPU Neurosensory Disorders
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 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
The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first?
Call the physician immediately.
A client with a suspected brain tumor is scheduled for computed tomography (CT). When preparing the client for this test, what nursing intervention does the nurse implement?
Determining whether the client is allergic to iodine, contrast dyes, or shellfish
The nurse is caring for a client with stroke in evolution. Which nursing intervention is priority?
Have tracheal suction available at all times.
What is the function of cerebrospinal fluid (CSF)?
It cushions the brain and spinal cord.
The physician prescribes diazepam, 10 mg I.V., for a client experiencing status epilepticus. Which action would the nurse follow when administering I.V. diazepam?
It should be administered no faster than 5 mg/minute in an adult.
A client is admitted with myasthenia gravis. Which nursing intervention should be priority?
Monitor respiratory status
A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?
Risk for injury
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 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 discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures?
activity of the brain
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 admitted to an acute care facility with a diagnosis of stroke. The nursing student is reviewing the client's history. Which history findings noted will the student report as risk factors for stroke? Select all that apply.
hypertension obesity smoking ½ pack of cigarettes a day hypertension
A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates that the client will need which procedure or program?
intermittent catheterization
When obtaining the health history from a client with retinal detachment, the nurse expects the client to report:
light flashes and floaters in front of the eye.
A graduate nurse, working in a long-term facility, is caring for a client who has hearing loss. When observing the graduate, the nurse mentor would intervene if which action is taken by the graduate?
moves around and multitasks when speaking
In caring for a child immediately after a head injury, the nurse notes a blood pressure of 110/60, a heart rate of 78 beats/minute, dilated and nonreactive pupils, minimal response to pain, and slow response to name. Which symptom would cause the nurse the most concern?
nonreactive pupils
The nurse is monitoring a client with a symptom of increased intracranial pressure (ICP) after head trauma. What observation does the nurse recognize as an early sign?
restlessness and confusion