Neuro 2

A client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, the nurse immediately:

Raises the head of the bed and removes the noxious stimulus

During the nursing history, which assessment data would the nurse expect the client scheduled for surgical correction of chronic open-angle glaucoma to report?

Recent motor vehicle crash while changing lanes

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?

Have the client stand erect with eyes closed

A client reports to the health care clinic for an eye examination and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the s/s associated with this disorder?

Have you had difficulty with peripheral vision?

A client with spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of recurrence?

Limiting bladder catheterization to once every 12 hours

A patient is admitted to the medical unit with a cerebrovascular accident (stroke). The patient is flaccid on the left side and is unable to speak but seems to understand everything the nurse says. Which of the following terms would the nurse use to document the patient's communication impairment?

Expressive aphasia

A nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client should be asked to:

Extend the tongue

A nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle accident. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation?

Extension of the extremities and pronation of the arms

A nurse is turning a postoperative client who had extensive back surgery yesterday. What turning intervention or position would be best for repositioning this client?

Logrolling

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding?

Fluid bubble seen behind the TM

A nurse is collecting data on a client who has experienced a left-hemispheric stroke. Which of the following manifestations should the nurse expect?

Frustrated about deficits

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

Loss of cognitive function

A nurse is collecting data on a male older adult client who has a new diagnosis of glaucoma. Which of the following findings should the nurse recognize as risks factors associated with this disease? Select all that apply

Genetic predisposition Eye trauma Age DM

A client who is recovering from a brain attack (stroke) has residual dysphagia. The licensed practical nurse instructs the nursing assistant to avoid which of the following at mealtime?

Giving the client thin liquids

A client with a brain attack (stroke) has residual dysphagia. When a diet prescription is initiated, the nurse avoids doing which of the following?

Giving the client thin liquids

When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress?

Glaucoma can be painless and vision may be lost before the person is aware of a problem.

A nurse is assigned to care for an adult client who had a brain attack (stroke) and is aphasic. Choose the appropriate interventions for communicating with the client. Select all that apply.

1. Face the client when talking. 2. Speak slowly and maintain eye contact. 3. Use gestures when talking to enhance words. 5. Give the client directions using short phrases and simple terms.

A nurse is contributing to the plan of care for a client who has dysphagia and a new dietary prescription. Which of the following interventions should the nurse include in the plan? Select all that apply

Have suction equipment Feed the client thickened liquids Place food on the unaffected side of the client's mouth Instruct the client to swallow with her neck flexed

The nurse is caring for a patient experiencing an acute exacerbation of MS. The nurse recognizes that symptoms of MS are caused by which of the following pathophysiological changes?

Demyelination and destruction of nerve fibers

The nurse is contributing to the plan of care for a client who has dysphagia. Which of the following should the nurse include in the plan of car? Select all that apply

Have suction equipment available for use Thicken liquids using a commercial thickener Instruct client to swallow with her neck flexed

A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the health care provider, and the nurse anticipates a prescription for which of the following medications?

Desmopressin (DDAVP)

A nurse is collecting data from a client who had increased ICP. Which of the following findings should the nurse expect? Select all that apply

Disoriented to time and place Restlessness and irritability Unequal pupils Headache

The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care?

Disturbed sensory perception

A nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech will be:

Associated with poor comprehension

The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care?

Decrease the amount of salt in the diet

A nursing is caring for a client who is at risk for increased ICP. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply

Decrease the noise level in the client's room Administer a stool softener

A nurse is caring for the client with a head injury secondary to a motor vehicle accident. The nurse observes the client's status regularly, monitoring closely for which changes in vital signs?

Decreasing pulse, decreasing respirations, increasing BP

The nurse is planning care for several clients and is considering the client's risk for stroke. Which of the following conditions places the client at risk for ischemic embolic stroke?

A client who has chronic Atrial Fibrillation

A nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that an early sign of rupture is which of the following?

A decline in the level of consciousness

A nurse is reinforcing discharge instructions with a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include?

Apply a cool cloth to the face during a headache

A nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin (Ditropan). The nurse evaluates the effectiveness of the medication by asking the client which of the following questions?

Are you getting up at night to urinate

A nurse is collecting data from a client who has a new diagnosis of MS. Which of the following findings should the nurse expect? Select all that apply

Areas of paraesthesia Involuntary eye movements Ataxia

A nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which of the following would indicate a basal skull fracture as a result of the injury?

Bloody or clear drainage from the auditory canal

he nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:

Blurred vision

A nurse is collecting data on a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? Select all that apply

Blurred vision White pupils

A nurse is trying to communicate with a brain attack (stroke) client with aphasia. Which action by the nurse would be least helpful to the client?

Completing the sentences that the client cannot finish

A nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which of the following indicates an early sign of increased ICP?

Confusion

A nurse is monitoring a client with a head injury and notes that the client is assuming this posture. The nurse notifies the registered nurse immediately to report that the client is exhibiting: Refer to figure.

Decorticate posturing

A nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which of the following findings? Select all that apply.

Drainage from ear Bruising around the eyes Pink-tinged drainage from the nose

A nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding would be an early indication that the level of consciousness (LOC) is deteriorating?

Drowsiness

A nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?

Electrodes will be injected into the skeletal muscles

A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which of the following being done by the family?

Encouraging the client to stand unassisted on the leg

The nurse is reviewing the health record of a client who has a middle ear disorder. Which of the following are expected findings?

Enlarged adenoids Report of recurrent colds Bulging tympanic membranes

A 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 of the following activities?

Exhaling during repositioning

A nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively?

Head of bed elevated 30 to 45 degrees, head and neck midline

A nurse is positioning the client with increased intracranial pressure (ICP). Which position should the nurse avoid?

Head turned to the side

The nurse is assisting the health care provider with performing a weber turning fork test on a client. What does this test assess for?

Hearing loss

A nurse is collecting neurological data on a post-stroke adult client. Which of the following techniques will the nurse perform to adequately check proprioception?

Hold the sides of the client's great toe and, while moving it, ask what position it is in

The nurse is caring for a client who just had a cataract surgery. Which of the following comments from the client should the nurse report to the provider?

I need something for the horrible pain in my eye

A nurse in a clinic is reinforcing teaching with a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching?

I should expect facial flushing when I take this medication

A nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further instruction?

I will not hear sounds clearly unless they are loud

A nurse is caring for a client who has experienced a right-hemispheric stoke. Which of the following findings should the nurse expect? Select all that apply

Impulse control difficulty Left hemiplegia Loss of depth perception Lack of situational awareness

The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.

In a semi-Fowler's position With the head in a midline position

A nurse is reinforcing teaching with a client who has a new diagnosis of macular degeneration. Which of the following instructions should the nurse include in the teaching?

Increase intake of deep yellow and orange vegetables

A nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, the nurse plans activities that will:

Increase the client's awareness of the affected side.

A nurse is caring for a client with increased intracranial pressure (ICP). The nurse should monitor for which of the following trends in vital signs that would occur if ICP is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure (BP)

A nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria if the client:

Indicates that facial puffiness will be a permanent problem

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the findings of migraine headaches?

Is there a pattern of headaches among family members?

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? Select all that apply

It is given to reduce swelling of the brain You may notice weight gain It can cause you to retain fluids

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse?

It is limited to brain tissue

The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. The nurse intervenes, based on the understanding that:

It is possible the client can hear the family.

A nurse is assisting in caring for a client with a supratentorial lesion. The nurse monitors which of the following as the critical index of central nervous system (CNS) dysfunction?

Level of consciousness

A 68-year-old client comes to the outpatient clinic and complains to the attending nurse his increased difficulty with "close-work" such as knitting. He indicates he does not have difficulty seeing objects on either side but does state that straight lines appear distorted or wavy. The nurse suspects which of the following disorders that is consistent with the client's reported symptoms?

Macular degeneration

A nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item would be included as part of the precautions?

Maintaining the head of the bed at 15 degrees

A nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse interprets that the client:

May likely have perceptual and spatial disabilities

A client was seen and treated in the emergency department for treatment of a concussion. The nurse determines that the family needs further discharge instructions if they say to bring the client back to the emergency department if which of the following occurs?

Minor headache

A client has just been admitted to the ER with an exacerbation of MS. Which of the following common manifestations of multiple sclerosis (MS) should the nurse be expecting? (Select all that apply)

Muscle spasticity Dysphagia Visual changes Fatigue

A nurse is preparing to care for a client with a diagnosis of brain attack (stroke). The nurse notes in the client's record that the client has anosognosia. The nurse plans care, knowing that the client will:

Neglect the affected side.

A client recovering from a craniotomy complains of a "runny nose." Based on the interpretation of the client's complaint, the best nursing action is to:

Notify the registered nurse.

A client is recovering at home after suffering a brain attack (stroke) 2 weeks ago. A home caregiver tells the home health nurse that the client has some difficulty swallowing food and fluids. Which nursing action would be appropriate as a first action?

Observe the client feeding himself or herself

An older client is at risk for falls. When developing an individualized plan of care for this client, the nurse recalls that which concept is least relevant to maintenance of balance for the older client?

Older clients cannot think quickly enough to respond to emergencies

A nurse is caring for an older adult client who has DM and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases?

Open-angle glaucoma

A nurse is assisting with the care of a client following surgical evacuation of a subdural hematoma. Which of the following data is the priority to monitor?

Oxygen Saturation

A client with a brain attack (stroke) is experiencing residual dysphagia. The nurse would remove which of the following food items that arrived on the client's meal tray from the dietary department?

Peas

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following interventions should the nurse implement?

Place the bedside table on the right side of the bed

. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which of the following in the client's record?

Positive Romberg's test

The nurse is collecting data on a client being admitted with a possible brain tumor. The nurse asks the client to stand with the feet together and the arms at the side and then close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on these findings the nurse documents which in the client's record?

Positive Romberg's test

The nurse is caring for a client admitted with an acute exacerbation of her multiple sclerosis. Which drug therapy does the nurse anticipate administering to help resolve an exacerbation?

Prednisone

A nurse is providing care to a client with increased intracranial pressure (ICP). Which approach(es) may be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply.

Reducing environmental noise Maintaining a calm atmosphere Allowing the client uninterrupted time for sleep

A nurse has instructed the family of a brain attack (stroke) client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will:

Remind the client to turn the head to scan the lost visual field.

An emergency department nurse is assigned to assist in caring for a client who has suffered a head injury following a motor vehicle accident. The nurse understands that the initial data collection should focus on which of the following?

Respiratory status

The nurse is assisting the admission of a client with a concussion following a motor vehicle accident. The nurse's observation of the client should include monitoring for early signs of increasing ICP including?

Restlessness and irritability

A nurse is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods?

Salted Cashews

A nurse is assisting with caring for a client after a craniotomy. The nurse plans to position the client in a:

Semi-Fowler's position

A nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client should be maintained in which of the following positions?

Semi-Fowler's position

A nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which of the following is noted?

Severe, throbbing headache

A nurse is contributing to the plan of care for a client who has global aphasia (both receptive and expressive). Which of the following interventions should the nurse include in the client's plan? Select all that apply

Speak to the client at a slower rate Assist the client to use flash cards with pictures Give instructions one step at a time

The nurse is assisting with a community education program related to cerebral vascular accidents. What should be included in a list of symptoms that need immediate medical attention? Select all that apply

Sudden trouble seeing in one or both eyes Sudden severe headache with no known cause Sudden confusion, trouble speaking, or understanding Sudden trouble walking, dizziness or loss of balance or coordination Sudden numbness or weakness of face, arm, or leg, especially on one side of the body

The nurse is assisting a neurosurgeon examine a patient who has a positive Babinski reflex. What assessment finding should the nurse expect to observe?

The big toe extends and the other toes fan out when the sole of the foot is stroked

A client with quadriplegia 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 nursing care?

The client is reacting to loss of control.

A nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign if noted in the client would the nurse report immediately?

The client vomits

A client has been newly diagnosed with glaucoma. As a part of the discharge instructions, what is the following most important for the nurse to include?

The need for lifelong medication on therapy

A client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse would plan on leaving the cervical collar in place until:

The result of spinal x-rays is known.

A nurse is reinforcing teaching with a client who has MS and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching?

This medication may cause your shin to appear yellow in color

The nurse is discussing the care for a client who has the suspected Meniere's disease. What would the nurse say is an expected finding?

Unilateral sensorineural hearing loss

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 of the following items?

Walker

A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will:

Wear the patch continuously, alternating eyes each day

A nurse is planning care for the client with hemiparesis of the right arm and leg. The nurse incorporates in the care plan placement of objects:

Within the client's reach, on the left side

A nurse is reinforcing postoperative teaching with a client following cataract surgery. Which of the following statements should the nurse include in the teaching?

You need to limit your housekeeping activities

A nurse in a provider's office is collecting data from a client who has cluster headaches. Which of the following findings should the nurse expect? Select all that apply

client experiences altered sleep-wake cycle headache occurs at approximately the same time of the day Nasal congestion and drainage occur