MS: Neurosensory

A nurse is providing teaching to the partner of a client who has a new dx of parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is priority? A. Dysphagia B. Emotional lability C. Impaired speech D. Self-care dependency

A.

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? A. The client rigidly extends his arms. B. The client internally flexes his wrists. C. The client curls into a fetal position. D. The client internally rotates his legs.

A. A client who exhibits a decerebrate posture rigidly extends and pronates his four extremities and externally rotates his wrists. Decerebrate posturing indicates severe brain stem injury and late neurologic decline.

A nurse is assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. Widened pulse pressure B. Tachycardia C. Periorbital edema D. Decrease in urine output

A. A widening of the pulse pressure, the difference between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting.

A nurse is teaching a client who has a new dx of simple partial seizures about auras. Which of the following statements by the client indicates an understanding of the teaching? A. "An aura is a sensory warning that a seizure is imminent." B. "An aura is a continuous seizure in which seizures occur in rapid succession." C. "An aura is a period of sleepiness following the seizure." D. "An aura is a brief loss of consciousness accompanied by staring."

A. An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor.

A nurse is performing a neurologic assessment for a client who has a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? A. Dysphagia B. Positive Babinski sign C. Decreased deep-tendon reflexes D. Ataxia

A. Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).

A nurse is assessing a client who has a closed head injury and has received mannitol for manifestations of ICP. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? A. The client's serum osmolarity is 310 mOsm/L. B. The client's pupils are dilated. C. The client's heart rate is 56/min. D. The client is restless.

A. Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.

A nurse is assessing a client who has a new dx of mastoiditis. Which of the following manifestations should the nurse expect? A. Swelling behind the affected ear B. Facial drooping on the affected side C. Nystagmus on the affected side D. Pearly gray color of the affected eardrum

A. Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear.

A nurse is providing teaching to the family of a client who has a new dx of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following finding is an early manifestation of ALS? A. Sensory dysfunction B. Weakness of the distal extremities C. Decreased vision D. Altered temperature regulation

B. ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord causing muscle wasting, spasticity, and eventually paralysis. Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet), speech, swallowing, and breathing.

A nurse is assessing a client who is unconscious and has a rhythmical breathing pattern of rapid deep respiration, followed by rapid shallow respiration, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respiration? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul

B. Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths, followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death. Paradoxical respirations, or a flail chest, is a pattern of breathing in which the chest wall contracts during inspiration and expands during expiration. This can occur in a client who has sustained rib fractures.

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 objects that weigh more than 25 pounds."

B. The client should avoid reading and any activity that can cause rapid movement of the eye because of the risk for detachment of the retina.

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings 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

B. 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 nurse is providing teaching to a client who has a new dx of migraine headaches about interventions to reduce pain at the onset of a migraine. Which og 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."

B. The nurse should instruct the client to lie down in a dark room to reduce migraine pain.

A nurse is assessing a client who has a new dx 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

C.

A nurse is caring for a client who is post op following a frontal craniotomy. The nurse should place the client in which of the follwoing positions? A. Trendelenburg B. Prone C. Semi-Fowler's D. Sims'

C.

A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment data the nurse should collect to determine a change in the client's neurologic status? A. Vital signs B. Body posture C. Level of consciousness D. Examination of pupils

C. A change in the client's level of consciousness can be the first indication of a change in neurologic status.

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching? A. Dry the ear canal with a cotton swab after swimming. B. Apply an ice pack to the ear to relieve pain. C. Instill a diluted alcohol solution into the ear after swimming. D. Irrigate the ear with cool tap water to clean.

C. External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal.

A nurse is assessing a client who has Guillain Barre syndrome. Which of the following finding should the nurse expect? A. Tonic-clonic seizures B. Report of a severe headache C. Weakness of the lower extremities D. Decreased level of consciousness

C. Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.

A nurse is providing teaching to a client who has a new dx 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

C. Ménière's disease is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.

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? A. Metered-dose inhaler B. Continuous passive motion machine C. Oral-nasal suction equipment D. External defibrillator pads

C. The client who has myasthenia gravis is at risk for aspiration because of progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle 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 nurse is teaching a client who has a new dx of primary open angle glaucoma. Which of the following information 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 the 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.

D, E Eye drops will not improve vision; however, they can reduce intraocular pressure and prevent further vision loss. Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can cause complete vision loss if not treated Laser surgery can reopen the trabecular meshwork and widen the Canal of Schlemm.

A nurse is 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? A. The client has a new tattoo. B. The client is unable to sit upright. C. The client has a history of peripheral vascular disease. D. The client has a pacemaker.

D.

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching? A. A high-pitched sound heard in the ear B. Intermittent rapid eye movement C. Itching on the external canal D. Feeling of fullness in the ear

D. A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain, a cracking sound when yawning or swallowing, and mild dizziness.

A nurse is assessing a client who has a high thoracic spine 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

D. Autonomic dysreflexia is a neurologic 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 nurse is providing teaching to the family of the client who has stage II Alzheimer's disease. Which of the following info should the nurse include in the teaching? A. Place abstract pictures on the wall in the client's room. B. Provide music for the client using headphones. C. Reorient the client to reality frequently. D. Limit choices offered to the client.

D. Choices should be limited for the client who has stage II AD to reduce confusion and frustration.

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 ml/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following lab values should the nurse plan to obtain to assess for DI? A. Blood urea nitrogen (BUN) B. Blood glucose C. Urine ketones D. Specific gravity

D. Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, infection, or a tumor. It is a condition in which an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.

A nurse is teaching a client who has myopia about laser assisted in situ keratomileusis (LASIK) surgery. The nurse should include in the teaching that which of the following is an adverse effect of LASIK surgery? A. Eyelid twitching B. Photosensitivity C. Intraocular hemorrhage D. Dry eyes

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 nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis. B. A TIA can be the result of cerebral bleeding. C. A TIA can cause cerebral edema. d. A TIA can precede an ischemic stroke.

D. TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include loss of vision in one eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.

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

B. An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase of protein in the cerebrospinal fluid.

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of 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.

B. The nurse should apply the safety and risk reduction priority-setting framework. This framework 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 nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The client is at greatest risk for injury from hitting his head; therefore, the first action is to protect the client's head from injury.

A nurse is providing discharge teaching to a cliet who is post op following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions? A. "I will sleep on the affected side." B. "I will avoid bending over." C. "I will restrict caffeine in my diet." D. "I will take aspirin to relieve my pain."

B. The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can result in intraocular hemorrhage.