ATI med-surg neuro

An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? A. monitor urinary output B. administer osmotic diuretic C. Provide supplemental oxygen D. initiate seizure precautions

correct answer: C The nurse should use ABC approach to client care. All others should be done but giving oxygen is priority.

presbyopia

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.

What medications cause tinnitus?

-loop diuretics (furosemide) -NSAIDs (aspirin, ibuprofen, naproxen) -SSRI's (fluoxetine) -Tricyclic medication (amitriptyline) -antianxiety (alprazolam) -Ace inhibitors (lisinopril) -Cancer med (cisplatin, methotrexate)

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? A. Add gestures when speaking with the client. B. Ask open-ended questions C. Limit visitors to 3 at a time D. Use different words if the client does not understand a statement

correct answer: A The nurse should use gestures when speaking with the client to increase the client's understanding of the conversation. B. the nurse should ask questions that can be answered with yes or no to reduce the client's confusion C. the nurse should limit visitors to 2 at a time to reduce the client's confusion D. the nurse should use the same words when repeating a statement to reduce the client's confusion

What is mastoiditis?

inflammation of the temporal bone behind the ear. Manifestations are: swelling and pain behind the ear and a red, thick eardrum.

A nurse is reviewing the lab results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? A. Elevated glucose B. Elevated protein C. Presence of RBCs D. Presence of D-dimer

Correct answer: B A lumbar puncture is a diagnostic test in which CSF is extracted for examination. Manifestations of bacterial meningitis include increased protein in the CSF. A. manifestations of bacterial meningitis include decreased glucose in the CSF. C. RBCs present in the CSF can be an indication of bleeding; however, the presence of WBCs in the CSF indicates bacterial meningitis. D. D-dimer measures coagulation activity and is used to evaluate blood clotting. The presence of D-dimer in the CSF is not a manifestation of bacterial meningitis.

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing of the lower extremities B. Hypotension C. Tachycardia D. Report of a headache

Correct answer: D Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension. A. manifestations of autonomic dysreflexia include flushing above the level of injury and pallor below the level of injury. B. Manifestations of autonomic dysreflexia include hypertension. C. Manifestations of autonomic dysreflexia include bradycardia.

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? A. occipital B. temporal C. frontal D. limbic

correct answer: C. The nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thoughts. A. occipital= vision B. temporal= understanding speech D. limbic= memory and learning

A nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following is an adverse effect of LASIK surgery? A. eyelid twitching B. photosensitivity C. intraocular hemorrhage D. dry eyes

correct answer: D Lasik surgery is a procedure that can correct nearsightedness, farsightedness, and astigmatism by changing the shape of the cornea. Adverse effects of LASIK surgery include dryness of the eyes and blurred vision. A. there is no surgical manipulation of the nerves of the face, eyelid, or eyeball; therefore tics or twitching of the eyelid are not associated with LASIK surgery. B. photosensitivity (sensitivity of the skin to light) is not an adverse effect of LASIK surgery. C. Intraocular hemorrhage is an adverse effect of cataract surgery, not LASIK surgery.

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A. multiple floaters B. flashes of light in front of the eye C. severe eye pain D. double vision

correct answer: C Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headaches, brow pain, and nausea and vomiting. A. multiple floaters are manifestations of a detached retina. B. Flashes of light in front of the affected eye is a manifestation of a detached retina. D. double vision is a manifestation of multiple sclerosis.

The nurse is preparing a client for an EEG. Which of the following pieces of information should the nurse share with the client? A. Expect the test to take about 3 hrs. B. You'll begin by lying still with your eyes closed. C. You'll sleep for the duration of the procedure. D. Expect some mild electrical shocks during the test.

Correct answer: B The client will have to lie still in a reclining chair or bed and keep her eyes closed for the initial recording. A. An EEG takes 45mins to 2hrs C. The nurse should explain the need to lie still but should also prepare the client for other activities such as hyperventilation and photic stimulation from flashing strobe lights. D. An EEG documents brain activity. Electrical shocks are not used during this test.

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure. This increase in ICP is due to which of the following? A. Decreased cerebral perfusion B. Leakage of cerebral spinal fluid. C. Rigid skull containing cranial contents D. Brain herniated into the brainstem

Correct answer: C The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP. A. A decrease in cerebral perfusion is a result of increasing ICP. B. Leakage of CSF occurs with a basilar skull fracture, which is an open traumatic injury rather than a closed traumatic injury. D. Brain herniation can occur as a result of untreated increased ICP and can lead to death. It is not a cause of increased ICP.

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? A. You can expect your vision to return immediately after the procedure B. You should avoid reading for 1 week. C. You can remove eye shields when you're sleeping D. You should not lift object that weigh more than 25lb

Correct answer: B. The client should avoid readiing and any activity that can cause rapid movement of the eye due to risk of detachment of the retina. A. The client's vision should return gradually over several weeks. C. The client should wear eye shields to sleep for 2-6 weeks after surgery, to protect the eyes from injury. D. The client should not lift objects that weigh more than 20lbs to prevent an increase in intraocular pressure.

A nurse is assessing a client who reports an acute visual disturbance that he describes as a curtain pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders? A. Cataracts B. Angle-closure glaucoma C. Retinal detachment D. Macular degeneration

Correct answer: C. The retina is a thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of supportive tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field. A. A cataract is a clouding that develops in the lens of the eye over time. Cataracts slowly impair vision and, without treatment, lead to blindness. Manifestations include decreased color perception and blurry vision. B. Angle-closure (acute) glaucoma results from a sudden shift in the position of the iris of the eye that blocks the outflow of aqueous humor. This leads to an acute onset of a severely painful rise in intraocular pressure. Angle-closure glaucoma is an emergency. Manifestations include a sudden onset of severe pain around the eyes and face, reduced vision, colored halos, and headaches. D. Macular degeneration results in a loss of vision in the center of the visual field (the macula) because of damage to the retina. Manifestations include a gradual mild to moderate reduction of central vision.

A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the client's coworker about the mechanism of injury. B. Check the client's pupils for equality and reaction to light. C. Measure the client's alertness using the Glasgow coma scale. D. Immobilize the client's cervical spine.

Correct answer: D The greatest risk to this client is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury. Therefore, the priority action the nurse should take after assessing the client's ABC is immobilizing the client's neck with a cervical collar. A client who has had head trauma might also have damage to the cervical spine. This is an essential component of the initial stabilization of a client who has a head injury. A. The nurse should question the client's coworkers about the mechanism of injury, which can yield information that will aid the treatment of the client's injury. However, another action is the nurse's priority. B. The nurse should check the client's pupils for equality and reaction to light to help determine if the client has increased ICP from a cerebral hemorrhage. However, another action is the nurse's priority. C. The nurse should measure alertness using the GCS to determine the client's LOC. However, another action is the nurse's priority.

A nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? A. Wernicke's area B. Cerebral cortex C. Basal ganglia D. hypothalamus

correct answer: D The nurse should identify that the hypothalamus, located below the cerebrum of the brain, is responsible for the regulation of body temperature. A. Wernicke's area is responsible for language and speech comprehension, not the regulation of body temperature. B. The cerebral cortex is involved in complex thought processes and higher function of the brain. C. The basal ganglia are involved in a variety of functions, including motor control and learning, but no the regulation of body temperature.

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? A. administer nifedipine B. Place the client in high-fowler's position C. check for urinary retention D. check for a fecal impaction

Correct answer: B. According to evidence based practice, the nurse should first place the client in a high-Fowler's position to decrease the client's blood pressure and reduce the risk of end-organ damage from the sudden rise in blood pressure. A. The nurse should plan to administer nifedipine to treat sudden severe hypertension, which can be life threatening and requires immediate administration of an antihypertensive medication. However, evidence-based practice indicates that the nurse should take a different action first. C. The nurse should check for urinary retention since this can be the stimulus that discharges the sympathetic reflex. The sympathetic reflex can cause manifestations of sudden hypertension, a throbbing headache, nasal congestion, flushing, sweating, and apprehension. However, evidence-based practice indicates that the nurse should take a different action first. D. The nurse should check for fecal impaction since this can be the stimulus that discharges the sympathetic reflex. However, evidence-based practice indicates that the nurse should take a different action first.

A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis. Which of the following pieces of information should the nurse include? A. use enemas to treat constipation caused by daily medications. B. Take a hot bath when muscles ache. C. Eat a low-calorie diet D. Set an alarm to ensure medication dosages are taken on time.

Correct answer: D The nurse should instruct the client to take med dosages on time to maintain a therapeutic blood level. Dosages should not be missed or postponed because this can cause an exacerbation of the disease. A. The nurse should instruct a client who has MG not to use enemas or strong cathartics because these can cause weakness and exacerbate the disease. B. The nurse should instruct the client to avoid becoming overheated by saunas, hot baths, or sunbathing. Being hot can cause an exacerbation of the disease. C. The nurse should instruct the client to eat a high-cal diet because weight loss often occurs with MG.

A nurse is providing preoperative teaching for a client who will undergo LASIK surgery. Which of the following information should the nurse include? A. you might need glasses after the surgery. B. you may drive home after the procedure. C. Continue to wear your contact lenses until the day of surgery. D. expect complete healing and clear vision in about a week.

correct answer: A LASIK is a type of refractive laser eye surgery that opthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or undercorrection of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery. B. the client might receive sedation prior to the procedure and postoperatively might have blurry vision, tearing, and hypersensitivity to light. C. Clients should not wear soft contact lenses for 2-3 weeks or hard contact lenses for 4 weeks prior to LASIK. Lenses omit oxygen to the cornea, which slows post-op healing. D. For some clients, vision is clear in an hour after surgery; however complete healing and optimal vision can take up to 4 weeks to occur.

During a neuro assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing? A. Remote B. Sensory C. Immediate D. Recall

correct answer: A. Remote The nurse tests remote or long-term memory by asking questions such as where and when the client was born, his age, when he graduated high school, and what the names, ages, and birth dates of his children. The nurse can later verify this information with the client's family or friends. B. sensory memory is a short-term, momentary recollection of some form of stimuli from the environment. C. The nurse tests immediate or new memory by giving the client a 3-step command and observing for completion of all 3 steps. D. The nurse tests recall memory by asking questions about recent activities that the nurse can verify in the client's medical record such as how the client got to the facility or which provider he saw in the past few days.

A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a curtain across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? A. glaucoma B. retinal detachment C. macular degeneration D. Cataracts

correct answer: B A flash of light and sudden loss of vision are manifestations of retinal detachment. Clients report the event of vision loss as sudden and painless. A. Manifestations of glaucoma include sudden, severe pain around the eyes. The pain often radiates over the face, and the client reports a headache, halos around lights, and sudden blurred vision. C. Manifestations of macular degeneration include a decline of central vision leading to a total loss. Clients often report mild blurring and distortion. D. Manifestations of cataracts include blurred vision and decreased color perception at first, followed by a lens of cloudiness that continues gradually until a loss of vision occurs in all visual fields.

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? A. visualizing the eardrum before irrigating B. instilling 50ml of fluid with each irrigation. C. using firm, continuous pressure while irrigating D. warming the irrigation fluid to at least 37 degrees C

correct answer: B when irrigating a client's ear, the nurse should use no more than 5-10ml of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in nausea, vomiting, or dizziness. The nurse should stop irrigating if the client experiences pain, nausea, vomiting, or dizziness. A. the nurse should use an otoscope to check the location of the impacted cerumen and verify the eardrum is intact before beginning the irrigation. In order to visualize the ear, the nurse should select a speculum that fits comfortably in the client's ear. C. After the client tilts the head slightly toward the unaffected ear, the nurse should gently pull the auricle of the affected ear upward and backward. During irrigation, the nurse should apply gentle but firm continuous pressure, allowing the water to flow against the top of the ear canal. D. warming the irrigation fluid to 37 C will reduce the chance of stimulating the vestibular nerve of the inner ear, which would result in nausea, vomiting, or dizziness.

A nurse is providing teaching to a client who has a new diagnosis of migraine about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? A. place a warm compress on your forehead B. darken the lights C. light a scented candle D. drink a caffeinated beverage

correct answer: B. The nurse should instruct the client to lie down in a dark room to reduce migraine pain. A. a cool cloth on the forehead reduces migraine pain C. avoid scents that can increase the severity of a migraine D. avoid foods that trigger migraines such as caffeine

A nurse in a rehab center is performing an assessment for a client who is recovering from a left-hemisphere stroke. What finding should the nurse expect? a. reduced left-side motor function b. difficulty with speech c. impulsive behavior d. neglect of the left side of the body

correct answer: B. Difficulty with speech. The left hemisphere of the brain is usually the dominant side and is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication. A. A client who is recovering from a left-hemisphere stroke will have hemiplegia of the right side of the body because the pyramidal pathway crosses over at the base of the brain. C. A client who is recovering from a right-hemisphere stroke can be impulsive. Clients recovering from a left-hemisphere stroke are cautious. D. A client who is recovering from a right-hemisphere stroke can neglect the left side of the body. The client can inadvertently injure an arm or leg since the client cannot feel or see anything on the left side of the body.

A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure? A. battle's sign B. periorbital edema C. dilated pupils D. halo sign

correct answer: C Dilated pupils can indicate that intracranial pressure is increasing. This finding should be reported to the provider immediately. A. Battle's sign is bruising behind the ears and lower jaw that can occur from the trauma of a skull fracture. It does not indicate increased intracranial pressure. B. Periorbital edema is a result of facial trauma. It does not indicate increased ICP. D. A halo sign is a clear or yellow ring surrounding a spot of fluid or blood from the nose or ear. The ring indicates leakage of cerebral spinal fluid that can occur with a skull fracture. It dose not indicate increased ICP.

A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching? A. avoid bearing down B. Increase caffeine intake C. Avoid sudden movements D. Increase sodium intake

correct answer: C Meniere's disease is a disorder of the inner ear affecting balance and hearing. It is characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations. A. bearing down (using the valsalva maneuver) does not increase the manifestations of Meniere's disease. B. The nurse should instruct the client to avoid caffeine and to drink an evenly distributed amount of fluids throughout the day to stabilize fluid levels in the body. D. The nurse should instruct the client to reduce sodium intake and drink and evenly distributed amount of fluids throughout the day to stabilize fluid levels in the body.

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the bedside? A. Metered-dose inhaler B. continuous passive motion machine C. oral-nasal suction equipment D. external defibrillator pads

correct answer: C. a client who has myasthenia gravis is at risk of aspiration due to progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress. A. MDI is for a client with asthma B. continuous passive potion machine is for a client who is postop after joint surgery. D. External defibrillator pads are used for a client who has cardiac dysrhythmia.

A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils? A. red tag B. yellow tag C. green tag D. black tag

correct answer: D The nurse should assign a black tag, or class IV label to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are poor prognostic sign and indicate severely increased ICP. In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible. A. red tags are assigned to those with life-threatening injury but high possibility of survival once they are stabilized. B. yellow tags have major injuries that are not yet life-threatening. C. green tags should be assigned to clients who have minor injuries that are not life threatening and do not need immediate attention.

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? A. reorient the client B. protect the client's head c. loosen constrictive clothing d. turn the client on his side

correct answer: b The nurse should apply the safety and risk reduction priority setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The client's greatest risk for injury from hitting his head; therefore, the first action is to protect the client's head from injury. A. all others should be done but b is the priority.

A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual cause of MS. Which of the following responses should the nurse make? A. each client is different; we cannot predict what will happen. B. I can see that you are worried, but it's too soon to predict what will happen. C. acute episodes are usually followed by remissions, which can vary in duration. D. it's too early to think about the future; let's focus on the present and take each day as it comes.

correct answer: c The client is asking an information-seeking question, so the nurse should provide the client with factual information. The nurse should inform the client that MS is a chronic autoimmune disorder characterized by remissions and exacerbations, with exacerbations becoming more frequent and intense as the disease progresses.

A nurse is teaching a client who has a new diagnosis of primary open angle glaucoma. Which should the nurse include in the teaching? select all that apply A. lost vision can improve with eye drops B. administer eye drops as needed for vision loss. C. glasses will be necessary to correct teh accompanying presbyopia. D. driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.

correct answers: D, E Damage to the optic nerve that occurs secondary to intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen the canal of Schlemm. A. eye drops will not improve vision; however, they can reduce intraocular pressure and prevent further vision loss. B. The client should administer eye drops on a regular schedule to reduce intraocular pressure. C. Presbyopia, which is a decreas in near vision that occurs after 40 years of age, is not related to POAG. Vision loss that occurs with POAG will not improve with glasses.

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? Select all that apply. A. Place the client in respiratory isolation B. Monitor vital signs every 2 hours C. Assess neurological status every 4 hours D. Maintain the client in a modified Trendelenburg position E. Keep the client's room darkened

correct answers: b,c,e The nurse should monitor the client's vital signs to assess for changes consistent with increased ICP. In addition, the nurse should monitor the client's neurological status at least every 4 hours or more frequently if the client's status indicates. The course of encephalitis is unpredictable, so the client should be monitored closely for any indications of deteriorating neurological functioning. The nurse should provide the client with a low-stimulation environment to promote comfort and decrease agitation.