Neuro. Chp. 37-1, 37-2, EXTRA EXTRA

71 The client with Guillain-Barré syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome?

"Antibodies that triggered the autoimmune response are removed from your blood."

55 The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care?

"Clients and families are the focus of hospice care."

79 A client, with a recent closed head injury, began experiencing partial (focal) seizures and asks the nurse to explain why this is happening. Which is the best response from the nurse?

"It is not uncommon for seizure activity to occur after head trauma."

4 A client with an inoperable brain tumor says to the nurse, "I'm so afraid that I'm going to die alone." What is the nurse's best response?

"You sound frightened."

32 A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam 0.25 mg/kg. How many milligrams will be given to this client?

15

16 A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

31) 37-2

31) 37-2

61) EXTRA EXTRA

61) EXTRA EXTRA

29 A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?

70 mm Hg

13 The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?

Administer medications at exact intervals ordered.

40 The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?

Administer medications at exact intervals ordered.

1 A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners.

36 The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

An absence seizure

80 A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam (Valium) 0.25 mg/kg. How many milligrams will be given to this client?

Ans: 15 mg Step 1: 2.2 lb / 1 kg = 132 lb / X kg 132 lb = 2.2 X 60 kg = X Step 2: 1 kg / 0.25 mg = 60 kg / X mg 15 mg = X

12 An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention?

Assess for a patent airway.

45 A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client?

Assess neurological findings.

52 An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

9 The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is

Change in level of consciousness

18 Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.

Cloudy cerebral spinal fluid Purpura of hands and feet

54 Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.

Cloudy cerebral spinal fluid Purpura of hands and feet

30 The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?

Damage to the nerves that facilitate vision and hearing

58 The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?

Damage to the nerves that facilitate vision and hearing

10 The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids

3 The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest?

Eating small meals of soft consistency food.

26 A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed.

42 A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed.

69 A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed.

23 Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply.

Elevated systolic blood pressure Wide pulse pressure

57 Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply.

Elevated systolic blood pressure Wide pulse pressure

38 A client adopted at birth recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears?

Encourage client to verbalize fears.

77 A client, who was adopted at birth, recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears?

Encourage client to verbalize fears.

56 The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client?

Explaining hospice care and services

35 A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client?

Hopelessness

78 A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client?

Hopelessness

66 You are caring for a client with an inoperable brain tumor. What is a major threat to this client?

Increased ICP

50 The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?

Increased intracranial pressure

70 The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds

17 The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside?

Intubation tray and suction apparatus

34 The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside?

Intubation tray and suction apparatus

8 The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client?

Maintain head of bed (HOB) elevated at 30 to 45 degrees.

14 The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Maintaining a patent airway

75 Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease?

Maintaining a safe environment

11 A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Mannitol

39 A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Mannitol

5 The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer?

Mannitol

68 A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Mannitol (Osmitrol)

49 The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which nursing assessment is primary during this time of medication change?

Monitor vital sign fluctuation.

2 A client is receiving baclofen for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?

Muscle spasms

46 A client is receiving baclofen for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?

Muscle spasms

63 A client you are caring for experiences a seizure. What would be a priority nursing action?

Protect the client from injury

60 A client the nurse is caring for experiences a seizure. What would be a priority nursing action?

Protect the client from injury.

37 Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

Seizure was 1 minute in duration including tonic-clonic activity.

76 The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline (Eldepryl) with carbidopa-levodopa (Sinemet) to the medication regime should result in which purpose?

Slows the progression of the disease

41 A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?

Suicidal ideations

67 A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?

Suicidal ideations

62 The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest?

Take small meals of nutrient and calorie-dense food.

44 A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?

Turn client to side-lying position.

24 A client with increased intracranial pressure is receiving mannitol via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment?

Urine output is increased.

59 A client with increased intracranial pressure is receiving mannitol via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment?

Urine output is increased.

81 A client with increased intracranial pressure is receiving mannitol (Osmitrol) via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment?

Urine output is increased.

19 Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy?

Use ophthalmic lubricant and protect the eye.

33 Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy?

Use ophthalmic lubricant and protect the eye.

74 Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy?

Use ophthalmic lubricant and protect the eye.

25 The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client?

Vector bites

15 An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

dehydrate the brain and reduce cerebral edema.

6 A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because

shivering in hypothermia can increase ICP.

21 A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?

unequal response

43 A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

"My children are at greater risk to develop this disease."

7 A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

"My children are at greater risk to develop this disease."

73 A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

"My children are at greater risk to develop this disease."

65 The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the nerves that facilitate vision and hearing

28 A client 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 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 should expect to observe which sign first?

Declining level of consciousness (LOC)

64 You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside?

Intubation tray and suction apparatus

27 Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Lethargy

53 Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Lethargy

51 The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Maintaining a safe environment

72 A client is receiving baclofen (Lioresal) for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?

Muscle spasms

20 A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication?

Decreased muscle spasms in the lower extremities

48 The nursing instructor gives their students an assignment of making a plan of care for a client with Huntington's disease. What would be important for the students to include in the teaching portion of the care plan?

How to facilitate tasks such as using both hands to hold a drinking glass

47 The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client?

Vector bites

22 A client suffered a closed-head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?

vasodilation