Mobility and Intracranial

The parents of a infant born with an abnormality on the back are told by the neonatologist that their child has a myelomeningeocele. They ask the nurse what exactly that means. Which would be the nurse's best reply? "The sac is a very small cyst and should resolve within the first year of life." "Your child's defect involves only the nerves to the bladder and bowel and can be easily repaired." "It is a herniation through the skin of the back of your child with both the spinal cord and nerve roots involved." "The contents of the sac you see only has fluid in it and should cause the child no problem."

"It is a herniation through the skin of the back of your child with both the spinal cord and nerve roots involved."

A nurse is teaching the parents of a child who has been diagnosed with spina bifida. Which statement by the nurse would be the most accurate description of spina bifida? "It's a complex neurologic disability that involves a collaborative health team effort for the entire first year of life." "It's a simple neurologic defect that's completely corrected surgically within 1 to 2 days after birth." "Its presence indicates that many areas of the central nervous system (CNS) may not develop or function adequately." "It has little influence on the intellectual and perceptual abilities of the child."

"Its presence indicates that many areas of the central nervous system (CNS) may not develop or function adequately.

A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response? "Treatment really doesn't matter; the disease is going to progress anyway." "Treatment for Parkinson's is only palliative; it keeps you comfortable." "Treatment aims at keeping you emotionally healthy by making you think you are doing something to fight this disease." "Treatment aims at keeping you independent as long as possible."

"Treatment aims at keeping you independent as long as possible."

A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

1.6

Which medication classification is used preoperatively to decrease the risk of postoperative seizures? Corticosteroids Anticonvulsants Antianxiety Diuretics

Anticonvulsants

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? Autonomic dysreflexia Tetraplegia Areflexia Paraplegia

Autonomic dysreflexia

The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? Provide a high-protein diet. Change the client's position frequently. Teach the client deep breathing and coughing exercises. Provide light massage at least daily.

Change the client's position frequently.

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting? Tonic clonic Decerebrate Flaccidity Decorticate

Decerebrate

A nurse is providing care to a client with Parkinson's disease. The nurse understands the the client's signs and symptoms are related to a depletion of which of the following? Acetylcholine Serotonin Dopamine Norepinephrine

Dopamine

A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as? Dysphagia Arthralgia Ataxia Dysarthria

Dysphagia

The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding? Hypokinesia Dysphonia Dysphagia Micrographia

Dysphonia

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? Absence Generalized Jacksonian Sensory

Generalized

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? Disturbed sensory perception (tactile) Dressing or grooming self-care deficit Impaired physical mobility Ineffective breathing pattern

Ineffective breathing pattern

The nurse will teach parents of children with myelomeningocele to maintain an environment free of what element? Peanuts Cat dander Latex Alcohol gel

Latex

The nurse is caring for a patient with Parkinson's disease and is preparing to administer medication. What does the nurse administer to the patient that is considered the most effective drug currently given for the tremor of Parkinson's? Permax Levodopa Symmetrel Requip

Levodopa

Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? Establishing balanced nutrition Maintaining a safe environment Enhancement of the immune system Involvement with diversion activities

Maintaining a safe environment

Which is the most common cause of spinal cord injury (SCI)? Motor vehicle crashes Sports-related injuries Falls Acts of violence

Motor vehicle crashes

The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? Observe for any signs of behavioral changes. Tylenol may be administered for aches. A light meal may be eaten if desired. Follow up with regular physician is encouraged.

Observe for any signs of behavioral changes.

What will be the nurse's next action after noting dimpling and a tuft of hair located in the lumbosacral area of the preschool child during examination? Record and refer the finding for follow-up to the pediatrician Snip the tuft of hair off close to the skin for hygienic reasons Move on to other assessments without calling attention to the difference Inspect for precocious hair growth in the genital and underarm areas

Record and refer the finding for follow-up to the pediatrician

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis? Noncompliance Ineffective coping Risk for injury Diarrhea

Risk for injury

A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client? Skin care Activity Safety Self-care

Safety

Which type of spinal neural tube defect does the nurse recognize as common and usually benign? Meningocele Spina bifida Spina bifida occulta Myelomeningocele

Spina bifida occulta

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? Spinal shock Hypertensive emergency Hypovolemia Epidural hemorrhage

Spinal shock

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? "People who experience a TIA will develop a stroke". "TIA is a warning sign. Let's talk about lowering your risks." "I sense that you are happy it was not a stroke". "TIA symptoms are shortlived and resolve within 24 hours".

"TIA is a warning sign. Let's talk about lowering your risks."

The earliest sign of serious impairment of brain circulation related to increased ICP is: A change in consciousness. Bradycardia. A bounding pulse. Hypertension.

A change in consciousness.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? Positive Babinski's reflex along with spastic extremities Hyperreflexia along with spastic extremities Absence of reflexes along with flaccid extremities Spasticity of all four extremities

Absence of reflexes along with flaccid extremities

Which of the following types of skull fractures may be evident by Battle's sign? Simple Depressed Comminuted Basilar

Basilar

A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response? "It has been linked to maternal alcohol consumption during pregnancy." "It's a common complication of amniocentesis." "The cause is unknown and there are many environmental factors that may contribute to it." "Older age at conception is one of the major causes of the defect."

"The cause is unknown and there are many environmental factors that may contribute to it."

A home care nurse makes a visit to a client with Parkinson's disease who is being cared for by his spouse. During the visit, the spouse says, "I'm just so tired. I have to do just about everything for him." Which response by the nurse would be most appropriate? "You're doing a great job. Just keep it up." "It must be difficult for you to see your husband like this." "Are you upset about how your husband is doing?" "You sound a bit overwhelmed. Tell me more about what's happening."

"You sound a bit overwhelmed. Tell me more about what's happening."

A client with Parkinson's disease is prescribed amantadine hydrochloride 100 mg twice a day. The pharmacy supplies amantadine syrup, because the client has a history of difficulty swallowing tablets. The label reads 50 mg/5 mL. How many milliliters would the nurse administer to the client for each dose? Enter the correct number ONLY.

10

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? Decreased heart rate Alteration in level of consciousness (LOC) Bradycardia Slurred speech

Alteration in level of consciousness (LOC)

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? Placing the client on a fluid restriction as ordered Administering an antifibrinolyic agent Applying thigh-high elastic stockings Assisting the client with passive range-of-motion (PROM) exercises

Applying thigh-high elastic stockings

A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first? Assist the client to the floor, in a side-lying position, and protect him with linens. Put a padded tongue blade into the client's mouth and restrain his extremities. Record the type of seizure and the time that it occurred. Initiate the code team response.

Assist the client to the floor, in a side-lying position, and protect him with linens.

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture? Basilar Simple Linear Comminuted

Basilar

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron-deficiency anemia. Which history finding is a risk factor for stroke? Being obese Being female Having bronchial asthma Being white

Being obese

The nurse is assessing a child with spina bifida occulta. During the assessment, the parents say, "It's going to be so difficult taking care of our child. He'll never be able to walk." The nurse identifies which nursing diagnosis as the priority? Risk for injury related to lack of muscle control Ineffective coping related to diagnosis of chronic condition Impaired physical mobility related to spinal cord defect Deficient knowledge related to diagnosis and condition

Deficient knowledge related to diagnosis and condition

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Talk in a louder than normal voice. Use one long sentence to say everything that needs to be said. Keep the television on while she speaks. Face the client and establish eye contact.

Face the client and establish eye contact.

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? Facial droop Periorbital edema Projectile vomiting Dysrhythmias

Facial droop

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Help the client sit upright when eating and feed slowly Instruct the client to lie on the bed when eating Offer liquids frequently, in large quantities Allow optimum physical activity before meals to expedite digestion

Help the client sit upright when eating and feed slowly

A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified? Advanced age Hypertension African heritage Male gender

Hypertension

The nurse receives a call from the caregiver of a client with a spinal cord injury. The caregiver informs you that the client has a reddened, macerated area at the base of the sacrum. What would the nurse suspect is going on with the client? They are getting spinal contractures. They are gaining weight. They have the beginning of a pressure sore. They need a bath

They have the beginning of a pressure sore.

A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing? Insert oral airway Place a cooling blanket on the client Turn the client to the side Administer mannitol

Turn the client to the side

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? L4 S2 T10 T6

t6

A client with Parkinson's disease has been receiving levodopa as treatment for the past 7 years. The client comes to the facility for an evaluation and the nurse observes facial grimacing, head bobbing, and smacking movements. The nurse interprets these findings as which of the following? Micrographia Dysphonia Bradykninesia Dyskinesia

Dyskinesia

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient? Dyskinesia Lactose intolerance Diarrhea Pruritus

Dyskinesia