Exam 8 Chapters 21 & 22

Sertraline (antidepressant)

- given with or without food - give once daily either in morning or evening - record mood changes - may increase suicidal thinking - avoid alcohol

Donepezil (anti-alzheimer)

- monitor patient for evidence of active or occult GI bleeding - monitor for bradycardia - take just before bedtime

Levodopa/Carbidopa (antiparkinsonian)

- observe patient and monitor vital signs, especially changes in BP, when changing positions. - hallucinations may require reduction or withdrawal of drug - take with food - don't crush or chew

Osmotic diuretics

Mannitol Treats Edema, increased ICP

Postoperative pain management for the patient with lumbar surgery may include: (select all that apply) a. use of ice packs on the area of back pain for up to 20 minutes each hour while awake for the first 48 hours b. NSAID medications can be given orally or IV c. complete bed rest to prevent injury to the operative are and promote comfort d. higher dosing of opioids delivered by PCA e. massage and warm whirlpool baths f. topical analgesic creams

a, b, c

A 40-year-old man with a T4 spinal cord injury suddenly complains of severe headache, increased pulse rate, sweating, flushing above the level of the spinal cord lesion, and "goosebumps" below the level of injury. Which immediate nursing action(s) should be taken? (select all that apply) a. place flat in bed b. identify the cause of stimulation c. administer ordered antihypertensives d. loosen tight clothing e. clamp indwelling catheter

b, c, d

Which nursing intervention(s) would be appropriate when providing care for a patient with right hemiplegia from a stroke? (select all that apply) a. reminding the patient to pay attention to the left side b. protecting the right extremities during transfers c. supporting the unaffected arm with pillows d. using a sling on the affected arm with pillows e. initiating ROM exercises

b, d, e

The nurse differentiates the sympathetic from parasympathetic nervous systems. Which statement about the sympathetic system is accurate? a. the sympathetic system slows the heart rate after a stressful situation b. the sympathetic system provides energy for fight or flight in stressful situations c. the sympathetic system supports deep sleep after large expenditures of energy d. the sympathetic system relaxes blood vessels to counteract hypertension

b. the sympathetic system provides energy for fight or flight in stressful situations

The nurse is caring for a patient with spastic paralysis. Which technique is most appropriate for the nurse to use when moving the patient? a. firmly grasp muscle to stabilize the extremity b. use the palms of the hands to support the joints c. log roll the patient onto the spastic side d. perform passive range of motion

b. use the palms of the hands to support the joints

The nurse is caring for a client with a neurogenic bowel due to a lower motor neuron spinal cord injury below T12 resulting in flaccid functionality. Besides triggering or facilitating techniques for defecation, what are some of the strategies the nurse needs to address to reestablish the defecation pattern? (select all that apply) a. limit fluids b. low-fiber diet c. suppository use d. manual disimpaction e. consistent toileting schedule f. drinks with caffeine and many soft drinks

c, d, e

The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? (select all that apply) a. epistaxis b. periorbital edema c. bruising behind the ear (battle sign) d. bruising around the eyes (raccoon eyes) e. purulent drainage from the auditory canal f. bloody or clear drainage from the auditory canal

c, d, f

An adult client with suspected meningitis has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis of a bacterial infection. The nurse checks for which value indicating a bacterial infection of the CSF. a. red blood cells b. decreased protein level c. decreased glucose level d. decreased white blood cells

c, decreased glucose level

The client has just undergone a computed tomography (CT) scan with a contrast medium. Which statement by the client demonstrated an understanding of postprocedure care? a. "I need to eat lightly for the remainder of the day." b. "I need to rest quietly for the remainder of the day." c. "I need to wait to take any medication for at least 4 hours."

d "I need to drink extra fluids for the remainder of the day."

Which medications would the nurse expect to be prescribed to effectively reduce nasal edema and rhinorrhea? (select all that apply) a. isoniazide b. terbutaline c. corticortopin d. oxymetazolin e. phenzopyridine f. pseudoephedrine

d, e

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? a. increasing temperature, increasing pulse, increasing respirations, decreasing BP b. decreasing temperature, decreasing pulse, increasing respirations, decreasing BP c. decreasing temperature, increasing pulse, decreasing respirations, increasing BP d. increasing temperature, decreasing pulse, decreasing respirations, increasing BP

d. increasing temperature, decreasing pulse, decreasing respirations, increasing BP

The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? a. is it grossly bloody in appearance and has a pH of 6 b. it clumps together on the dressing and has a pH of 7 c. it is clear in appearance and tests negative for glucose d. it separates into concentric rings and tests positive for glucose

d. it separates into concentric rings and tests positive for glucose

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? a. strictly adhering to a bowel retraining program b. keeping the linen wrinkle-free under the client c. avoiding unnecessary pressure on the lower limbs d. limiting bladder catheterization to once every 12 hours

d. limiting bladder catheterization to once every 12 hours

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How would the nurse interpret this? a. anorexia is a sign of clinical depression, and a referral to a psychologist is needed b. the client has compulsive habits that should be ignored as long as they are not harmful c. the client probably has a naturally slow metabolism, and the decreased nutritional intake won't matter d. meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable

d. meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable

look at pharm made easy

neuro 1 and 2 questions

The nurse has obtained a personal and family history from a client with a neurological disorder. Which findings in the client's history is least likely associated with a risk for neurological problems? a. allergy to pollen b. previous back injury c. history of headaches d. history of hypertension

a. allergy to pollen

The nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure. Which indicates an early sign of increased ICP? a. confusion b. bradycardia c. sluggish pupils d. a widened pulse pressure

a. confusion

Which of the following is the treatment of choice for diabetes insipidus? a. dextrose in 5% NS b. IV vasopressin and fluid replacement c. humalog on a sliding scale d. low carbohydrate diet

b. IV vasopressin and fluid replacement

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive romberg sign. Which of the following actions should the nurse take to check for this manifestation? a. stroke the lateral aspect of the sole of the foot b. ask the client to blink his eyes c. observe for facial drooping d. have the client stand erect with eyes closed

d. have the client stand erect with eyes closed

While reviewing a patient's chart you note that the patient has a condition known as expressive aphasia. What responses might you expect from the patient upon showing the patient a key and asking, "what is this?" a. the patient responds, "Argh ooh." b. the patient looks away and gazes out the window c. the patient responds, "it is a key, and it used to eat my food." d. the patient does not respond

a. the patient responds, "Argh ooh."

A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? a. walker b. slider board c. raised toilet seat d. adaptive eating utensils

a. walker

Which statement by a high school athlete being discharged after experiencing a concussion indicates a need for further teaching? a. "I can fo to football practice tomorrow." b. "I need to report a worsening headache to the health care provider." c. "I need to rest and not overdo activities." d. "I can expect to be more fatigued for a while."

a. "I can fo to football practice tomorrow."

The classic signs of increasing ICP include which of the following? (select all that apply) a. rising systolic blood pressure b. widening pulse pressure c. bradycardia d. positive Babinski sign

a, b, c

The nurse is providing care to a client with increased intracranial pressure. Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? (select all that apply) a. reducing environmental noise b. maintaining a calm atmosphere c. allowing the client uninterrupted time for sleep d. clustering nursing activities to be done all at once e. keeping overhead lights on most of the day and night

a, b, c

The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which? a. foot drop b. plantar flexion c. pressure ulcers d. deep vein thrombosis

a. foot drop

The nurse is planning care for a client with hemiparesis of the right arm and leg. Where would the nurse plan to place objects needed by the client? a. within the client's reach, on the left side b. within the client's reach, on the right side c. just out of the client's reach, on the left side d. just out of the client's reach, on the right side

a. within the client's reach, on the left side

When giving instructions to a patient with some dysphagia, further teaching is needed if the patient states: a. "I must sit upright when I eat." b. "I can watch my crime show on TV while I eat." c. "I should stay upright after eating for at least 30 minutes." d. "I should be calm and unhurried when eating."

b. "I can watch my crime show on TV while I eat."

The nurse has provided discharge instructions to a client with an application of a halo device. Does the nurse determine that the client needs further teaching if which statement is mad? a. "I will use a straw for drinking." b. "I will drive only during the daytime." c. "I will use caution because the device alters balance." d. "I will wash my skin daily under the lambs wool liner of the vest."

b. "I will drive only during the daytime."

Interruption of the thoracic spinal cord at which level causes paraplegia? a. C-5 b. L-2 c. T-10 d. L-8

b. L-2

A client with right hemiplegia is experiencing difficulty with mobility. The nurse determines that there is a need for further teaching if the nurse observes which action by the family. a. apply a premold splint b. performing active ROM to the affected leg c. encouraging the client to stand unassisted on the leg d. providing passive ROM to the affected leg

c. encouraging the client to stand unassisted on the leg

An adult client had a cerebrospinal analysis after lumbar puncture. The nurse interprets which finding as abnormal if present. a. protein b. glucose c. red blood cells d. white blood cells

c. red blood cells

The nurse is preparing to give a post-craniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." The nurse would formulate a response based on which understanding of codeine? a. codeine is one of the strongest opioid analgesics available b. codeine cannot lead to physical or psychological dependence c. codeine does not cause gastrointestinal upset or constipation as do other opioids d. codeine does not alter respiration or mask neurological signs as do other opioids

d. codeine does not alter respiration or mask neurological signs as do other opioids

The client with a cervical spine injury has crutchfield tongs applied in the emergency department. The nurse would perform which essential action when caring for this client? a. provide a standard bed frame b. remove the weights to reposition the client c. remove the weights if the client is uncomfortable d. compare the amount of prescribed weights with the amount in use

d. compare the amount of prescribed weights with the amount in use

The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? (select all that apply) a. bowel sounds are absent b. the client's abdomen is distended c. respiratory excursion is diminished d. the blood pressure rises when the client sits up e. accessory muscles of respiraiton are areflexic

a, b, c, e

The immediate elevation of blood pressure associated with autonomic dysreflexia can lead to which of the following complications? (select all that apply) a. seizure b. retinal hemorrhage c. pulmonary embolism d. stroke e. myocardial infarction

a, b, d

The nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure. Which sign, if noted in the client, would the nurse report immediately? a. the client vomits b. the client complains of feeling tired c. the client complains of pain at the site of injury d. the client complains of dizziness when getting out of bed for the first time

a. the client vomits

The nurse is caring for the client with a head injury secondary to a motor vehicle crash. The nurse observes the client's status regularly, monitoring closely for which change in vital signs that could indicate increased intracranial pressure? a. increasing pulse, increasing respirations, decreasing BP b. decreasing pulse, decreasing respirations, increasing BP c. decreasing pulse, increasing respirations, decreased BP d. increasing pulse, decreasing respirations, increasing BP

b. decreasing pulse, decreasing respirations, increasing BP

A 30-year-old man is admitted to the emergency department after a motor vehicle accident. After examination, the patient is diagnosed with a T6 spinal cord injury. He has flaccid paralysis, slowed heart rate, low blood pressure, and no bowel sounds. The patient must be developing: a. autonomic dysreflexia b. muscle spasms c. spinal shock d. diabetes insipidus

c. spinal shock

The unconscious patient with a closed head injury is on mechanical ventilation. To improve brain perfusion through increased blood pressure, the carbon dioxide should be maintained at what level? a. 10-15mmHg b. 15-20mmHg c. 20-30mmHg d. 25-30mmHg

d. 25-30mmHg

A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching? a. I will scan the room to see things b. I will wear rubber-soled shoes for walking c. I will use a walker for ambulating if I need to d. I will bend at the waist keeping the halo vest straight to pick up items

d. I will bend at the waist keeping the halo vest straight to pick up items

A nurse is receiving a transfer report for a client who has a head injury. The client has a glasgow coma scale 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? a. the client can follow simple motor commands b. the client is unable to make vocal sound c. the client is unconscious d. the client opens his eyes when spoken to

d. the client opens his eyes when spoken to

A nurse is admitting a patient with a possible basilar skull fracture. Which clinical finding(s) would likely confirm the diagnosis? (select all that apply) a. battle sign b. partial blindness c. ecchymosis around the eyes d. rhinorrhea e. swallowing difficulty

a, c, d

A nurse is collecting data from a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimuli is within normal limits? a. pushes the painful stimulus away b. extends the body part toward the stimulus c. shows no reaction to the painful stimulus d. flexes the upper and extends the lower extremities

a. pushes the painful stimulus away

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse would avoid which action to maintain client safety after this procedure? a. keeping the head of the bed flat b. having the client use an overhead trapeze c. placing pillows under the length of the legs d. having the client use a logrolling technique for repositioning

b. having the client use an overhead trapeze

The nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 level if which clinical symptoms are observed? a. hypotension and tachycardia b. hypotension and bradycardia c. hypertension and tachycardia d. hypertension and bradycardia

b. hypotension and bradycardia

The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? a. vomiting b. minor headache c. difficulty speaking d. difficulty awakening

b. minor headache

A client with spinal cord injury has experienced more than one more episode of autonomic dysreflexia. The nurse would avoid which action that could trigger an episode of this complication? a. preventing pressure on the client's lower limbs b. rigidly adhering to a bowel retraining program c. allowing the client's bladder to become distended d. keeping the linen under the client free of wrinkles

c. allowing the client's bladder to become distended

The nurse is caring for a client who has undergone a craniotomy with a supratentorial incision. The nurse would plan to place the client in which position postoperatively? a. head of bed flat, and neck midline b. head of bed flat, head turned to the nonoperative side c. head of the bed elevated 30-45 degrees, head and neck midline d. head of bed elevated 30-45 degrees, head turned to the operative side

c. head of the bed elevated 30-45 degrees, head and neck midline

A nurse is monitoring a client for findings related to diabetes insipidus following a craniotomy. Which of the following findings should indicate a manifestations of this condition to the nurse? a. hypertension b. elevated blood glucose c. increased urine output d. fluid retention

c. increased urine output

A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse? a. ask the family to deliver the care b. leave the client alone until ready to participate c. advise the client that rehabilitation progresses more quickly with cooperation d. acknowledge the client's anger and continue to encourage participation in care

d. acknowledge the client's anger and continue to encourage participation in care

The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury? a. hypertension b. tachycardia c. profuse diaphoresis d. areflexia below the level of injury

d. areflexia below the level of injury

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve would identify a complication specifically associated with this surgery? a. cranial nerve I, olfactory b. cranial nerve IV, trochlear c. cranial nerve III, oculomotor d. cranial nerve VII, facial nerve

d. cranial nerve VII, facial nerve

A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity. a. squeezing rubber balls b. doing push-ups in a prone position c. extending the arms while holding weights d. doing active range of motion to finger joints

d. doing active range of motion to finger joints

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? a. providing sensory cues b. giving simple, clear directions c. providing a stable environment d. encouraging multiple visitors at one time

d. encouraging multiple visitors at one time

The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? a. blowing the nose b. isometric exercises c. coughing vigorously d. exhaling during repositioning

d. exhaling during repositioning

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain? a. cerebrum b. cerebellum c. hippocampus d. hypothalamus

d. hypothalamus

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects that the cervical collar will remain in place until which time? a. the client is taken for spinal x-rays b. the family comes to visit after surgery c. the nurse needs to provide physical care d. the primary health care provider reviews the x-ray results

d. the primary health care provider reviews the x-ray results

The nurse is assigned to care for a client with a diagnosis of hepatic encephalopathy. Which prescribed medication would the nurse most anticipate administering? a. phenolphthalein b. lactulose syrup c. magnesium hydroxide d. psyllium hydrophilic mucilloid

b. lactulose syrup lactulose syrup is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels.

A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown? (select all that apply) a. massage erythematous bony prominences b. implement turning schedule every 4 hr c. use pillows to keep heels off the bed surface d. keep environmental humidity less than 30% e. minimize skin exposure to moisture

c, e

The surgeon inserts an intraventricular catheter into the lateral ventricle of a patient with increased ICP. When asked by a relative about the procedure, an accurate response would be: a. "The catheter allows direct visualization of the brain tissue." b. "The catheter is used to monitor brain waves." c. "The catheter is used to remove excess fluid inside the brain." d. "The catheter is used to infuse fluids and medications into the brain."

c. "The catheter is used to remove excess fluid inside the brain."

With an open hand, you press over the flaccid bladder of a patient. When questioned regarding this nursing action, an appropriate response would be: a. "the technique increases the muscle tone of the bladder." b. "the maneuver facilitates removal of urinary sediments." c. "the technique assists with complete bladder emptying." d. "the technique reduces the incidence of bladder irritation."

c. "the technique assists with complete bladder emptying."

A 75-year-old patient who fell and hit his head a week ago is admitted for apparent personality changes, decreased level of consciousness, and irritability. The health care provider suspects a possible subdural hematoma. A family member asks about the condition. An accurate explanation would be: a. "It is the presence of bleeding in the brain parenchyma." b. Bleeding occurs between the skull and the dura mater." c. It is the condition of blood between the brain and the inner surface of the dura mater." d. "It is the intermittent blockage of circulation in various areas of the brain."

c. It is the condition of blood between the brain and the inner surface of the dura mater."

The student nurse is planning care for a patient with a recent spinal cord injury. Which intervention indicates that the student nurse requires further instruction regarding appropriate care for this patient? a. keep a halo jacket fastened unless the patient is in a supine position b. monitor the bladder every 4 hours for bladder distention c. instruct unlicensed assistive personnel to turn and reposition the patient every 2 hours d. assess compression stocking for proper fit

c. instruct unlicensed assistive personnel to turn and reposition the patient every 2 hours

The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which action should be done. a. increase fiber and fluids in the diet b. bend at the knees to pick up objects c. strengthen the back muscles by swimming or walking d. get out of bed by sitting straight up and swinging the legs over the side of the bed

d. get out of bed by sitting straight up and swinging the legs over the side of the bed

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first? a. check the client for fecal impaction b. ensure the room temperature is warm c. check the client's bladder for distention d. raise the head of the bed

d. raise the head of the bed

The client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure. a. supine, in semi-fowler's b. prone, in slight Trendelenburg c. prone, with a pillow under the abdomen d. side-lying, with legs pulled up and chin to the chest

d. side-lying, with legs pulled up and chin to the chest

You use the glasgow coma scale to evaluate the neurologic responses of a patient. The patient opens their eyes to pain, makes incomprehensible verbal sounds, and extends their extremities with pain. The score would suggest: a. locked-in syndrome b. brain death c. coma d. lethargy

c. coma

The nurse has been advised to monitor the patient for Cushing's triad, they correctly monitor their patient for which set of signs and symptoms? a. decreased LOC, widened pulse pressure, irregular respirations b. decreased LOC, narrowed pulse pressure, decreased pulse c. decreased heart rate, widened pulse pressure, irregular respirations d. increased heart rate, widened pulse pressure, irregular respirations

c. decreased heart rate, widened pulse pressure, irregular respirations

A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? a. taking the temperature b. observing for dyskinesia c. monitoring the respiratory rate d. checking extremity muscle strength

c. monitoring the respiratory rate

The nurse is caring for a client who has suffered a spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptoms is noted? a. sudden tachycardia b. pallor of the face and neck c. severe, throbbing headache d. severe and sudden hypotension

c. severe, throbbing headache

You are conducting a "neuro" check on a patient who is admitted with a stroke. Which assessments will be done? (select all that apply) a. direct light reflex b. balance and coordination c. plantar reflex d. vital signs e. muscle strength f. alertness and orientation

a, d, e, f

A client with a seizure disorder is being admitted to the hospital. Which would the nurse plan to implement for this client? (select all that apply) a. pad the bed's side rails b. place an airway at the bedside c. place suction equipment at the bedside d. tape a padded tongue blade to the wall at the head of the bed

a, b, c, d

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? a. observing for facial asymmetry b. checking pupillary responses to light c. eliciting the gag reflex d. testing visual acuity

b. checking pupillary responses to light

A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which action to determine whether the client is ready to be sitting up? a. puts both of the client's hip joints through a full range of motion b. compares the client's pulse and blood pressure when both flat and sitting c. loosen the vest to gather data on the client's ability to support his own trunk d. inspects the halo vest pin sites to monitor for purulent drainage, redness, and pain

b. compares the client's pulse and blood pressure when both flat and sitting

A nurse scrapes an object along the sole of a patient's foot and notes that the great toe bends upward and the smaller toe fans outward. The clinical findings is suggestive of: a. sensory abnormality of the cortex b. motor abnormality of the cortex c. cerebellar tissue destruction d. a normal finding

b. motor abnormality of the cortex

You keep a postcraniaotomy patient's neck in the midline position and ensure that there is no excessive hip flexion. The rationale for your action would be that the position: a. restores neutral position of the joints b. prevents a further increase in intracranial pressure c. promotes comfort and rest d. prevents the formation of blood clots

b. prevents a further increase in intracranial pressure

The nurse observes the assistive personnel (AP) positioning the client with increased intracranial pressure (ICP). Which observation would require intervention by the nurse? a. the client's head is placed midline b. the client's head is turned to the side c. the client's neck is in neutral position d. the client's head of the bed is elevated 30-45 degrees

b. the client's head is turned to the side

The nurse knows they may implement nasal suction to clear secretions from the patient's airway only after which of the following diagnostic procedures has been performed? a. after the patient's gag reflex has been assessed b. after the GSC has been measured c. a CT has been performed to rule out a basilar skull fracture d. a LMA has been placed to maintain the patient's airway

c. a CT has been performed to rule out a basilar skull fracture

A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which reason? a. pressure on the spinal cord b. pressure on the spinal nerve root c. muscle spasm in the area of the herniated disk d. excess cerebrospinal fluid production in the area

c. muscle spasm in the area of the herniated disk

You are providing discharge instructions to an older adult male who experienced a stroke. You notice that the patient seems indifferent to teaching. You must consider: a. talking to the spouse or daughter b. involving the entire family in the care of the patient c. sending the patient to a long-term care facility d. stopping and trying again later

a. talking to the spouse or daughter

A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching? a. I need to catheterize myself twice a day b. I carry a water bottle with me because I drink a lot of water c. I use a suppository every night to have a bowel movement d. I do my wheelchair exercises sitting in my chair

a. I need to catheterize myself twice a day

Which information will the nurse reinforce to the client scheduled for a lumbar puncture? a. informed consent will be required b. the test will probably take about 2 hours c. food and fluids will be restricted until after the test is completed d. there is no need to maintain a supine position following the test

a. informed consent will be required

The family of an unconscious client with increased intracranial pressure is talking at the bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How would the nurse interpret the client's situation? a. it is possible the client can hear the family b. the family needs immediate crisis intervention c. the client may have wanted a visit from the hospital chaplain d. the family could benefit from a conference with the primary health care provider

a. it is possible the client can hear the family

In assessing the patient with a significant right intracerebral hemorrhage, the nurse anticipates that the patient will demonstrate which signs? a. left-sided hemiplegia with dilated right pupil b. right-sided hemiplegia with brisk right pupil response c. bilateral motor hemiplegia with bilaterally dilated pupils d. left-sided hemiplegia and bilateral PERRLA

a. left-sided hemiplegia with dilated right pupil

The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of injury? a. moving the client quickly as one unit b. using vasopressor medications, as prescribed c. applying compression stocking, as prescribed d. monitoring vital signs before during position changes

a. moving the client quickly as one unit

A nurse is collecting data from a client who has an epidural hematoma. Which of the following manifestations should the nurse expect? a. lucid period followed by rapid loss of consciousness after the injury occurs b. headache and drowsiness 24-48 hours after the injury occurs c. neurological deficits that appear up to 2 weeks after the injury occured d. slowed thinking and confusion developing up to several months after the injury occured

a. lucid period followed by rapid loss of consciousness after the injury occurs

A nurse is contributing to the plan of care for a client who has a spinal cord injury resulting in paraplegia. Which of the following interventions should the nurse include? a. provide a high-protein, high-calorie diet b. perform passive range of motion exercises daily c. use sequential compression devices for 4hr three times a day d. develop a schedule to restrict fluid intake

a. provide a high-protein, high-calorie diet

You demonstrate an understanding of the physiologic changes in the nervous system associated with aging by: a. providing extra time for the patient to process and answer questions b. teaching the patient how to perform activities of daily living c. finishing the patient's sentences when they are responding to questions d. communicating slowly and loudly with low-pitched cry

a. providing extra time for the patient to process and answer questions

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action would the nurse take? a. raise the head of the bed and remove the noxious stimulus b. lower the head of the bed and removed the noxious stimulus c. lower the head of the bed and administer an antihypertensive agent d. remove the noxious stimulus and administer an antihypertensive

a. raise the head of the bed and remove the noxious stimulus

You assess the consensual reflex of the eyes. To do this, you: a. shine a light in one eye and observe for any change in the other eye's pupil b. have the patient look at an object in the distance and then at your fingers 6 inches from the eyes, observing for pupil constriction c. have the patient look as far in one direction as possible to determine whether the eyes go back and forth rapidly d. hold a tissue to the corner of the eye to see whether the patient blinks

a. shine a light in one eye and observe for any change in the other eye's pupil

A client with tetraplegia complains bitterly about the nurse's slow response to the call light and the rigidity of the therapy schedule. Which interpretation of this behavior would serve as a basis for planning care? a. the client is reacting to the loss of control b. the clients complains indicate depression c. the client must adjust to institutional schedules d. limits must be set on staff response time to call bells

a. the client is reacting to the loss of control

A nursing assistant is attending to the need of a patient with a head injury who is lethargic and has increased ICP. Which action by the nursing assistant indicates a need for further instruction? a. notifying the nurse of patient coughing b. monitoring blood pressure every shift c. keeping the patient NPO d. reporting blood on the dressing

b. monitoring blood pressure every shift

The nurse caring for a client with a neurological disorder is assisting in planning care to maintain nutritional status. The client has had a swallowing study done that shows the client is at risk for aspiration and is able to feed self. The nurse would review which interventions with the assistive personnel. (select all that apply) a. ass the prescribed thickener to liquids b. have the client sitting up at 45 degrees c. follow each swallow of food with a sip of water d. observe the client for episodes of coughing or choking e. take the client for a walk before the meal to provide stimulation

a, d

A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia. Which finding is indicative of this complication? a. pupil responses are brisk bilaterally b. the knee-jerk reaction is absent bilaterally c. one hundred mL of residual urine remains after the client voids. d. the client complains of a headache, and the blood pressure is elevated

d. the client complains of a headache, and the blood pressure is elevated

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? (select all that apply) a. prone position b. supine position c. semi-fowler's position d. dorsal recumbent position e. with the foot of the bed flat f. with the foot of the bed elevated 30 degrees

c, e

A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? a. speak loudly to the client b. place the client on aspiration precautions c. provide a clear path for ambulation without obstacles d. prohibit intensely smelling foods such as onions and tuna

c. provide a clear path for ambulation without obstacles