EXAM 3: NEURO ATI

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

"Have you had a recent influenza infection?"

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia dysmetria and sensory change. Which of the following nursing statements are appropriate?

"Implement a schedule to include periods of rest.

A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include?

"Vision will be greatly improved on the day of surgery."

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

A change in the Glasgow Coma Scale score from 13 to 11

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mmHg. Which of the following actions should the nurse take?

Adjust the clients head of the bed.

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide?

Alcohol increases the chance of phenytoin toxicity.

A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client the nurse observes clear fluid draining from the client's nose. Which of the following intervention should the nurse take?

Allow the drainage to drop onto a sterile gauze pad

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function?

Apply downward pressure while the client shrugs his shoulders upward.

A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching ?

Avoid bending at the waist.

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Call emergency services

A nurse is modifying the diet have a client who has Parkinson's disease and it's prescribed Selegiline an MAOI. Which of the following foods should the nurse eliminate?

Cheddar cheese

A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take?

Clear objects from the client's walking area

A client has increased intracranial pressure following a closed-head injury. The nurse should recognize which of the following interventions as contraindicated for this client?

Cough and deep breathe.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure

Decreased level of consciousness

A nurse is caring for a client who has Parkinson's disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see?

Decreased tremors

A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis?

Developing a respiratory infection

A nurse is teaching a client who taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects?

Difficulty voiding

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). The nurse should know that which of the following client findings supports this suspicion?

Diplopia.

A nurse is completing an assessment of a client who has increased ICP. Which of the following are expected findings? SATA

Disoriented to time and place,Restlessness and irritability,Unequal pupils,Headache

A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to speaks incoherently and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document?

E3 + V4 + M4 = 11

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? SATA

Elevate the head of the bed 15 to 30 degrees.,Contact the health care provider if ICP is greater than 20 mm Hg.,Monitor neurologic status using the Glasgow Coma Scale. 30,20,GCS

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.)

Have suction equipment available for useFeed the client thickened liquids.,Place food on the unaffected side of the client's mouth.,Teach the client to swallow with her neck flexed.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg pulse of 82/min respirations of 24/min and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke

A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the clients indicate an understanding of the teaching?

I will bend my knees when picking an object up off the floor.

A nurse is assessing a client who reports severe headache and a stiff neck. the nurses assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?

Implement droplet precautions.

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (Select all that apply.)

Implement seizure precautions.,Turn off room lights and television.,Monitor for impaired extraocular movements.

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?

Inability to recognize familiar objects.

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Inability to recognize his family members.

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Increase fluid intake

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Instruct the client to look up and down without moving his head

A nurse is caring for a school-age child who sustained a closed head injury. Which of the following findings is an early indicator of increased intracranial pressure?

Irritability

A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take?

Maintain the client on absolute bed rest.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Manifestations preceded by a severe headache

A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure?

Mannitol

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Muscle contractions become progressively stronger.

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? Select all that apply.

Muscle distortion,Pain behind the ear,Impaired taste

A nurse is shopping and finds a woman who has collapsed with right sided weakness and slurred speech. Which of the following actions should the nurse take?

Notify emergency management services.

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

Perform a Romberg's test.

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

Prepare the client for mechanical ventilation.

A nurse is creating a plan of care for a client who has tonic-clonic seizures disorder. Which of the following seizure precautions should the nurse implement? (Select all that apply)

Provide a suction setup at the bedside.,Elevate the side rails when in bed.,Place the bed in the lowest position.,Keep an oxygen setup at the bedside.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision.

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

Reduce Stimuli.

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following statements indicates the nurse understands the rationale for using this solution?

Reduce edema of the brain.

A nurse caring for a client who had a right sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following action should the nurse take?

Remind the client to look for food on the left side of the tray

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

Restlessness

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Severe headache

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Severe headache.

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Small drops of clear fluid in left ear

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?

Speak to the client about one idea at a time

A nurse is caring for a client who has global aphasia. Which of the following should the nurse include in the clients plan of care?

Speak to the client at a slower rate,Assist the client to use cards with pictures,Give instructions one step at a time

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale the nurse determines that the client's score has changed from 11 to 15. Which of the following responses did the nurse assess in this client?

Spontaneous eye opening.,Orientation to person, place, and time.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening 5 for best verbal response and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening 5 for best verbal response and 5 for best motor response. (13 total). Which of the following is an appropriate conclusion based on this data?

The client opens their eyes when spoken to

A nurse is providing teaching to the partner of a client who has Alzheimer's disease and has a new prescription for donepezil. Which how's the following statements by the partner indicates that teaching is effective?

This medication should help my husband daily function

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse closely monitor the client for increased intracranial pressure as indicated by which of the following findings?

Widened pulse pressure.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). To determine if the client is experiencing pain the nurse should use

a self-report pain rating scale.

A nurse is caring for a client who is post procedure following lumbar puncture and reports a throbbing headache when sitting up right. Which of the following actions should the nurse take?

assist the client to a supine position,administer in opioid medication,encourage the client to increase fluid intake

A nurse is monitoring a client who is at risk for increased intracranial pressure. While assessing the client's cranial nerves the nurse should check the function of cranial nerve III by

checking pupillary response to light.

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report

having a decreased ability to perceive colors.

A patient is scheduled for a lumbar puncture. The nurse will plan to

help the patient to a side lying position before the procedure.

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client

makes up stories when he is unable to remember actual events.

A newly admitted patient who has suffered a right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient the nurse should

place objects on the patient's left side to assess the patient's ability to compensate

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer?

Mannitol 25%

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

Minimize environmental stimuli.

A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

Decrease the noise level in the clients room,Administer a stool softener

A nurse is assessing a client who is experiencing autonomic dysreflexia. which of the following findings should the nurse expect?

Facial flushing ,Nasal Congestion,Headache

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?

Infection

The nurse is caring for a client after lumbar puncture. The client reports a severe headache. Which actions should the nurse complete? Select all that apply.

Maintain the client on bed rest.,Administer fluids to the client,Administer analgesic medication.

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a sitting position.

An acute care nurse receives shift report for a client with increased intracranial pressure and is told the client demonstrates decorticate posturing. Which of the following should the nurse expect to observe upon assessment of this client?

Plantar flexion of the legs

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?

Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week

A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include in the plan?

Avoid reading and writing

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? Select all that apply

Loosen restrictive clothing.,Place a pillow under the client's head.

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following findings are expected? Select all that apply.

Impulse control difficulty,Left hemiplegia,Loss of depth perception,Lack of situational awareness I,L,L,L

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect

Bradykinesia

A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement to prevent foot-drop?

Support the right foot in dorsiflexion with a footboard.

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

Suction saliva from the client's mouth.

A nurse is caring for a client diagnosed with Guillain-Barre syndrome. Which assessment findings require nursing action? SATA

BP of 80/42,Shallow breathing pattern,Peripheral oxygen saturation of 85%,Diminished breath sounds in all lung fields

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Bradycardia, Nonreactive dilated pupils, Pressure

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mmHg. Which of the following findings should the nurse identify as a late sign of ICP? SATA

Bradycardia,Non-reactive dilated pupils,Widened pulse pressure BPP

A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action

Check the drainage for glucose.

A nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions by the nurse is appropriate?

Elevate the head of the bed 30 degrees.

A nurse is implementing precautions for a client who has a cerebral aneurysm. Which of the following nursing intervention should the nurse implement?

Encourage exhaling through mouth during defecation

A nurse is caring for a client who reports a severe headache following a lumbar puncture. Which of the following actions should the nurse take?

Encourage oral fluids.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Encourage the client to take small bites.

A nurse at a rehabilitation center is planning care for a client who has a left hemispheric cerebral accident CVA three weeks ago. Which of the following goals should the nurse include in the clients rehabilitation program?

Establish the ability to communicate effectively.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Evaluate the client's neurological status.

A client exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the emergency department. The provider determines the patient's injury is causing increased intracranial pressure (ICP). The nurse utilizes the Glasgow Coma Scale (GCS) to determine the change in the patient's level of consciousness. The nurse knows that which of the following is included in the Glasgow Coma Scale (GCS)? SATA

Eye opening response,Verbal response,Motor response E,V,M

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? SATA

Headache,Slurred speech,Pupillary changes,Disorientation

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Irritability

A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instruction should the nurse include?

Keep your head up and straight

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?

Monitor sensory perception of the lower extremities.

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment?

Oxygen saturation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mmHg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a high-Fowler's position.

A nurse is developing a plan of care for a client who is postoperative following a pneumatic retinopexy to repair a detached retina. which of the following intervention should the nurse include in the plan?

Position the client prone

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications?

Respiratory compromise

A nurse is caring for a client who has just had an evacuation of a subdural hematoma following a head injury. Which of the following is the nurse's highest priority assessment?

Respiratory status

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Restlessness

A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching?

"Syncope episodes may occur when taking this medication."

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

"Move objects away from the client."

A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include?

"Restrict lifting objects greater than 10 pounds"

A nurse is caring for a client who is going to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make?

"The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible."

A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?

The client should wear dark glasses while outdoors.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side.

The nurse is caring for a postoperative client who has undergone a transsphenoidal hypophysectomy. Which assessments would be most important for this client? Select all that apply

Urinary output, Fluid and electrolyte balance, Visual assessment

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?

Use log rolling to reposition the client

A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure which of the following findings should the nurse expect?

Violent headache,Slurred speech,Projectile vomiting,Rapid loss of consciousness (P,R,S,H)