Medical-Surgical: Neurosensory

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?

The client rigidly extends his arms

A nurse is collecting data from a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect?

Weakness of the lower extremities

A nurse in a rehabilitation center is collecting data from a client who is recovering from a left hemisphere stroke. Which of the following findings should the nurse expect?

Difficulty with speech

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. The nurse should recognize which of the following findings is consistent with this diagnosis?

Elevated protein

A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery?

Intraocular hemorrhage

A nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. Which of the following data is the priority for the nurse to collect to detect a change in the client's neurologic status?

Level of consciousness

A nurse is reinforcing discharge teaching with 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?

Protect the client's head

A nurse is reinforcing teaching about auras with a client who has a new diagnosis of simple partial seizures. Which of the following statements by the client indicates an understanding of the teaching?

An aura is a sensory warning that a seizure is imminent

A nurse is reinforcing teaching with a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching?

Avoid sudden movements

A nurse is collecting data from a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?

Cheyne-Strokes

A nurse is reinforcing teaching with a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?

Darken the lights

A nurse is reinforcing teaching with a client who has a new diagnosis of primary open angle glaucoma (POAG). Which of the following information should the nurse include in the teaching?

Driving can be dangerous due to the loss of peripheral vision. Laser surgery can help reestablish the flow of aqueous humor.

A nurse is collecting data from a client who has a brain tumor. Which of the following findings indicates cranial nerve involvement?

Dysphagia

A nurse is reinforcing teaching with the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority?

Dysphagia

A nurse is reinforcing teaching with a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

Feeling of fullness in the ear

A nurse is reinforcing teaching with a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the teaching?

I will avoid bending over

A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

Instill a diluted alcohol solution into the ear after swimming.

A nurse is reinforcing teaching with the family of a client who has stage 2 Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching?

Limit choices offered to the client

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 client's bedside?

Oral nasal suction equipment

A nurse is collecting data from 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?

Report of a headache

A nurse is caring for a client who has a closed head injury. The nurse should place the client in which of the following positions?

Semi-Fowler's

A nurse is collecting data from 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?

Severe eye pain

A nurse is collecting data from a client who has a recent head trauma and a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to monitor for DI?

Specific gravity

A nurse is collecting data from a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?

Swelling behind the affected ear.

A nurse reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure?

The client has a pacemaker

A nurse is collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates to the nurse that the medication is having a therapeutic effect?

The client's urine output is 250 mL/hr

A nurse if reinforcing teaching with the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS?

Weakness of the distal extremities

A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

Widened pulse pressure

A nurse is reinforcing discharge teaching with 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?

You should expect to see flashing lights in front of the affected eye after the procedure

A nurse is reinforcing teaching with a group of clients about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching?

A TIA can precede an ischemic stroke