NCLEX 300-NEURO
The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal?
Urine retention or incontinence
When self-administering atropine (Atropisol), the nurse should instruct the client to wait how long between instilling the first drop and instilling the second drop?
2 to 3 minutes
The nurse on the neurologic unit must provide care for four clients who require different levels of care. Which client should the nurse assist first with morning care?
A client who requires minimal bathing assistance and ambulates with a walker independently
A client with quadriplegia is in spinal shock. What should the nurse expect?
Absence of reflexes along with flaccid extremities
The nurse is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common?
Muscle weakness
A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which of the following objectives is appropriate?
Promoting weight-bearing exercises
The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?
Schedule the medication before meals.
Damage to which area of the brain results in receptive aphasia?
Temporal lobe
To evaluate a client's cranial nerve function, the nurse should assess:
gag reflex.
The nurse is caring for a client with an acute bleeding cerebral aneurysm. The nurse should take all of the following steps except:
keep the client in one position to decrease bleeding.
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:
place the client on his side, remove dangerous objects, and protect his head.
The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in a room set at a comfortable temperature.
What should the nurse do when administering pilocarpine (Pilocar)?
Apply pressure on the inner canthus to prevent systemic absorption.
The nurse is collecting data on a geriatric client with senile dementia. Which neurotransmitter condition is likely to contribute to this client's cognitive changes?
Decreased acetylcholine level
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?
Helicopod
A client is having a tonic-clonic seizure. What should the nurse do first?
Take measures to prevent injury.
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:
a positive edrophonium (Tensilon) test.
When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:
elevate the head of the bed 90 degrees during meals.
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?
"Avoid stimulants and alcohol for 24 to 48 hours before the test."
A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?
"I'm sorry you haven't been bathed. I'm available to bathe you now."
A client who's receiving phenytoin (Dilantin) to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?
10 to 20 mcg/ml
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention would reduce the client's risk of increased intracranial pressure (ICP)?
Administering a stool softener as prescribed
A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?
Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.
The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is:
Alzheimer's disease.
The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
Elevate the head of the bed to 30 degrees.
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?
Elevated 30 degrees
While bathing a client who sustained a stroke, a nurse is asked by a coworker to assist with repositioning another client. What should the nurse do?
Ensure the client's privacy, put up the side rail, and explain that she'll return shortly.
The nurse assesses normal pupils in a client who had a craniotomy, and then writes "PERRLA" in the nurse's notes, along with other findings. What does the "E" stand for in this acronym?
Equal
The nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?
Establishing an intermittent catheterization routine every 4 hours
A client is hospitalized with Guillain-Barré syndrome. Which data collection finding is most significant?
Even, unlabored respirations
A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin (Dilantin) to control seizures, the nurse assesses for which common adverse drug reaction?
Excessive gum tissue growth
A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints?
Fasten the restraint to the bed frame using a quick-release knot.
The nurse is teaching a client and his family about baclofen (Lioresal) therapy. Baclofen is an analogue of which neurotransmitter?
Gamma aminobutyric acid (GABA)
A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
Hemiplegia, seizures, and decreased level of consciousness (LOC)
The nurse formulates a nursing diagnosis of Risk for imbalanced body temperature for a client who suffers a stroke after surgery. The expected outcomes incorporate assessment of the client's temperature to detect abnormalities. The thermoregulatory centers are located in which part of the brain?
Hypothalamus
A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease?
II
Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?
In 10 to 15 minutes
A physician diagnoses a client with myasthenia gravis and prescribes pyridostigmine (Mestinon), 60 mg by mouth every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine?
Intestinal obstruction
What is the function of cerebrospinal fluid (CSF)?
It cushions the brain and spinal cord.
The physician prescribes diazepam (Valium), 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true?
It should be administered no faster than 5 mg/minute in an adult.
How should the nurse position a client for a lumbar puncture?
Laterally, with knees drawn up to the abdomen and chin touching the chest
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
Midbrain
During the course of a busy shift, a nurse fails to document that a client's ventricular drain had an output of 150 ml. Assuming that the drain was no longer draining cerebrospinal fluid, the physician removes the drain. When the nurse arrives for work the next morning, she learns that the client became agitated during the night and his blood pressure became elevated. What action should the nurse take?
Notify the physician of the documentation omission.
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?
Obesity
After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?
Perform a lumbar puncture.
A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
When caring for a client with a head injury, the nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?
Rising blood pressure and bradycardia
A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The spouse tells the nurse of feeling guilty for letting the accident happen and reports not sleeping well because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?
Risk for caregiver role strain related to increased client care needs
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority?
Risk for injury related to neurologic deficit
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?
Risk for injury related to vertigo
The parents of a client who sustained a closed head injury in a motor vehicle accident voice their concerns about the distance and cost of the rehabilitation center chosen for their son. Which health care team member can help the parents with their questions and concerns?
Social worker
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects which neuromuscular blocking agent to be administered?
Succinylcholine (Anectine)
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?
Suction machine with catheters
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
The client uses a mirror to inspect his skin.
A client accidentally splashes chemicals into his eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment?
To prevent vision loss
A client with hypertension comes to the clinic for a routine checkup. Because hypertension is a risk factor for cerebral hemorrhage, the nurse questions the client closely about warning signs and symptoms of hemorrhage. Which complaint is a possible indicator of cerebral hemorrhage in this client?
Vertigo
The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?
Vision changes
A 58-year-old client complaining of difficulty driving at night states that the "lights bother my eyes." The client wears corrective glasses. The nurse would suspect that the client is experiencing a deficiency in which of the following vitamins?
Vitamin A
The physician prescribes mannitol (Osmitrol) I.V. stat for a client who develops increased intracranial pressure after a head injury. While preparing to administer mannitol, the nurse notices crystals in the solution. What should the nurse do?
Warm the solution in hot water to dissolve the crystals.
If a client experienced a stroke that damaged the hypothalamus, the nurse would anticipate that the client has problems with:
body temperature control.
Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called a:
conductive hearing loss.
The client asks the nurse, "How does ergotamine (Ergostat) relieve migraine headaches?" The nurse should respond that it:
constricts cerebral blood vessels.
A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:
demonstrate eyedrop instillation.
A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:
increase the frequency of the catheterizations.
A client with an inflammatory ophthalmic disorder has been receiving a ½-inch ribbon of corticosteroid ointment in the lower conjunctival sac four times per day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent:
increased intraocular pressure.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
raccoon eyes and Battle's sign.
A client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg by mouth twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:
treatment of spasticity associated with spinal cord lesions.
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
"Avoid hot baths and showers."
A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and heaviness. During the admission process, the client presents her advance directive, which states that she doesn't want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse respond?
"It's important for us to have this information. You should review the document with your physician at every admission."
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. What should the nurse tell the client about the paralysis?
"The paralysis caused by this disease is temporary."
A nurse on the neurologic unit evaluates her client care assignment after receiving the shift report. Which client in her assignment should she attend to first?
A client who sustained a fall on the previous shift and is attempting to get out of bed
A client injures his spinal cord in a diving accident. The nurse knows that the client will be unable to breathe spontaneously if the injury site is above which vertebral level?
C4
A client is thrown from an automobile during a collision. The nurse knows that the client will be able to maintain gross arm movements and diaphragmatic breathing if the injury occurs at what vertebral level?
C5
The nurse is performing a mental status examination on a client diagnosed with a subdural hematoma. This test assesses which of the following functions?
Cerebral function
A client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification?
Cholinergic blocker
After a motor vehicle accident, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?
Flat, except for logrolling as needed
A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?
Inner ear
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
Notify the physician.
A client is color blind. The nurse understands that this client has a problem with:
cones.
An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby health care facility. He receives emergency care for corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by:
decreasing leukocyte infiltration at the site of ocular inflammation.
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
electromyography (EMG).
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, this examination must be brief but should include:
evaluation of the corneal reflex response.
The nurse is teaching a client with a T4 spinal cord injury and paralysis of the lower extremities how to transfer from the bed to a wheelchair. The nurse should instruct the client to move:
his upper body to the wheelchair first.
After an eye examination, a client is diagnosed with open-angle glaucoma. The physician's prescription says "pilocarpine ophthalmic solution (Pilocar), 0.25% 1 gtt both eyes q.i.d." Based on this prescription, the nurse should teach the client or a family member to administer the drug by:
instilling one drop of pilocarpine 0.25% into both eyes four times daily.
When obtaining the health history from a client with retinal detachment, the nurse expects the client to report:
light flashes and floaters in front of the eye.
A client recovering from a stroke has right-sided hemiplegia and telegraphic speech and often seems frustrated and agitated, especially when trying to communicate. However, the chart indicates that the client's auditory and reading comprehension are intact. The nurse suspects that the client has:
nonfluent aphasia.
The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with:
thymus gland hyperplasia.
When teaching a client about levodopa and carbidopa (Sinemet) therapy for Parkinson's disease, the nurse should include which instruction?
"Be aware that your urine may appear darker than usual."
A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?
"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine (Cogentin), 0.5 mg by mouth daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine?
"I take the medication at bedtime."
(SELECT ALL THAT APPLY) The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan?
(3) Furnish the client's environment with familiar possessions., (4) Assist the client with activities of daily living (ADLs) as necessary., (5) Assign tasks in simple steps.
The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure. She monitors his blood pressure for signs of widening pulse pressure. His current blood pressure is 170/80 mm Hg. What is the client's pulse pressure?
90
After a stroke, a 75-year-old client is admitted to a health care facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which action is a priority for this client?
Elevating the head of the bed to 30 degrees
A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate?
Meningeal irritation
A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. What does this mean?
Muscle contraction is palpable and visible.
The nurse is monitoring a client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?
Tachycardia
The nurse is preparing a client for a computed tomography (CT) scan, which requires infusion of radiopaque dye. Which question is important for the nurse to ask?
"Are you allergic to seafood or iodine?"
A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Client teaching about this drug should include which instruction?
"Schedule follow-up visits with your physician for blood tests."
A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate?
"What has your physician told you about your ability to walk again?"
A quadriplegic client is prescribed baclofen (Lioresal), 5 mg by mouth three times daily. What is the principal indication for baclofen?
Muscle spasms with paraplegia or quadriplegia from spinal cord lesions
A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based on these findings, which action should the nurse take?
Notify a physician of the findings.
The nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness.
The nurse observes that a comatose client's response to painful stimuli is decerebrate posturing. The client exhibits extended and pronated arms, flexed wrists with palms facing backward, and rigid legs extended with plantar flexion. Decerebrate posturing as a response to pain indicates:
dysfunction in the brain stem.
A client injured in a train derailment is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:
hypoxia.
For a client with suspected increased intracranial pressure (ICP), the most appropriate respiratory goal is to:
promote carbon dioxide elimination.
To encourage adequate nutritional intake for a client with Alzheimer's disease, the nurse should:
stay with the client and encourage him to eat.
A nurse is caring for a group of clients on the neurologic unit. Which task should the nurse perform first?
Arrange an escort for a client who needs to go to the physical therapy department.
A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?
Assist the client to a side-lying position on the floor, and protect her with linens.
A 78-year-old Alzheimer's client is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to:
wander.
(SELECT ALL THAT APPLY) A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client?
(1) Assist the client to the floor., (2) Turn the client to his side., (3) Place a pillow under the client's head.
(SELECT ALL THAT APPLY) A client with tonic-clonic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Which instructions about phenytoin should the nurse give this client?
(1) Monitor for skin rash., (3) Perform good oral hygiene, including daily brushing and flossing., (4) Periodic follow-up blood work is necessary., (5) Report to the physician problems with walking and coordination, slurred speech, or nausea.
(SELECT ALL THAT APPLY) A client is admitted to the medical-surgical unit after undergoing intracranial surgery to remove a tumor from the left cerebral hemisphere. Which nursing interventions are appropriate for the client's postoperative care?
(2) Turn the client on his right side., (5) Apply a soft collar to keep the client's neck in a neutral position.
(SELECT ALL THAT APPLY) A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture?
(2) Wrist pronation, (3) Stiff extension of the arms and legs, (4) Plantar flexion of the feet (5) Opisthotonos
A client has an exacerbation of multiple sclerosis accompanied by leg spasticity. The physician prescribes dantrolene sodium (Dantrium), 25 mg by mouth daily. How soon after administration can the nurse expect to see a significant reduction in spasticity?
1 to 2 weeks
The physician orders measurement of the serum acetaminophen level of a client admitted with a suspected overdose of this drug. To ensure an accurate result, the nurse should wait how long after acetaminophen (Tylenol) ingestion before drawing the blood sample?
4 hours
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Monitoring the patency of an indwelling urinary catheter
The physician determines that a client's chronic, progressive hearing loss results from excess bone formation around the oval window, which impedes normal stapes movement and prevents sound transmission. What is the clinical term for this correctable middle ear disorder?
Otosclerosis
The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:
destruction of acetylcholine receptors.
A client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When assessing this client, the nurse expects to note:
vertigo, tinnitus, and hearing loss.
A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?
Risk for injury
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
Attaching braces or splints to each foot and leg
A client who sustained a closed head injury in a motor vehicle accident is diagnosed as brain dead by a neurosurgeon. The physician has scheduled a meeting with the client's family about discontinuing life support. Before the meeting, a family member asks the nurse her opinion about life support. Which response by the nurse is appropriate?
"What has the physician explained about the client's prognosis?"
(SELECT ALL THAT APPLY) The nurse is planning care for a client with multiple sclerosis. Which problems should the nurse expect the client to experience?
(1) Visual disturbances, (3) Balance problems, (5) Mood disorders
(SELECT ALL THAT APPLY) The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate that he understands the instructions?
(2) "I'll try to chew my food on the unaffected side.", (4) "Drinking fluids at room temperature should reduce pain.", (5) "If brushing my teeth is too painful, I'll try to rinse my mouth instead."
For a client with a head injury whose neck has been stabilized, the preferred bed position is:
30-degree head elevation.
The nurse receives a physician's order to administer 1,000 ml of normal saline solution I.V. over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/ml?
31
The nurse is preparing to administer carbamazepine (Tegretol) oral suspension, 150 mg by mouth. The pharmacy has dispensed carbamazepine suspension 100 mg/5 ml. How many milliliters of carbamazepine should the nurse administer to the client?
7.5
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
An isolation room close to the nurses' station
On the 5th postoperative day, a client who underwent spinal fusion begins to complain of nausea and has an episode of vomiting. How should a nurse intervene?
Auscultate the abdomen for bowel sounds.
The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first?
Call the physician immediately.
A client who experienced a stroke that left her with residual right-sided weakness was just discharged to go home. The client lives in a two-story house in which the bathroom is located on the second floor. A home health care nurse is visiting the client for the first time. Which issue should the nurse address during this visit?
Client's ability to climb the stairs while using a walker
Family members would like to bring in a birthday cake for a client with nerve damage. What cranial nerve needs to be functioning so the client can chew?
Cranial nerve V
The neurologic unit has identified a 30% occurrence of pressure ulcers in clients admitted with the diagnosis of stroke. Which of the following actions should be included in the unit's performance improvement plan?
Creating a spreadsheet on which nursing staff should document repositioning of clients admitted with a stroke
A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then he became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse would expect to observe which sign first?
Declining level of consciousness
A client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
Edrophonium (Tensilon)
When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?
Increased intracranial pressure (ICP)
In a client with amyotrophic lateral sclerosis and respiratory distress, which finding is the earliest sign of reduced oxygenation?
Increased restlessness
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant?
Increased urine output
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
Ineffective airway clearance
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?
Ineffective breathing pattern
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. In this syndrome, polyneuritis leads to progressive motor, sensory, and cranial nerve dysfunction. On admission, which assessment is most important for this client?
Lung auscultation and measurement of vital capacity and tidal volume
A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?
Make arrangements for the client to receive information about advance directives.
A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do?
Make sure a tonsil suction device is readily available while providing mouth care.
A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis?
Powerlessness
The nurse is planning care for a client who suffered a stroke in the right hemisphere of his brain. What should the nurse do?
Provide close supervision because of the client's impulsiveness and poor judgment.
When caring for a client with head trauma, the nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do?
Test the nasal drainage for glucose.
A client comes to the clinic for an ophthalmologic screening, which will include measurement of intraocular pressure with a tonometer. When teaching the client about the test, the nurse should cover which point?
The tonometer will register the force required to indent or flatten the corneal apex.
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
carefully move him to a flat surface and turn him on his side.
The nurse is working on a surgical floor. The nurse must logroll a client following a:
laminectomy.
A client is diagnosed with a conductive hearing loss. When performing Weber's test, the nurse expects that this client will hear sound:
on the affected side by bone conduction.
A client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?
Lidocaine (Xylocaine)
During recovery from a stroke, a client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates:
cranial nerves IX and X.
