Neuro Practice Questions
The client diagnosed with a right sided cerebrovascular accident is in the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction 2. Turn and reposition the client every shift 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three times a day 5. Instruct the client to hold the fingers and a fist
1. placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture 3. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible. A written schedule may assist the client in exercising
Which measure should a nurse initially include in the plan of care for a client who has difficulty swallowing due to Parkinson's disease? 1. Arranging for someone to feed the client 2. Provide the client with semi solid foods or thicken liquids 3. Encouraging the client to drink fluids with meals 4. Placing food in the unaffected side of the clients mouth
2. And Parkinson's disease, the tongue may have poor control, which places the client at risk for aspiration. Semi solid food without lumps and thickened liquids stick together so that the tongue can direct the food bolus into the back of the mouth.
Which diagnostic test is used to confirm the diagnosis of Amyotropic Lateral Sclerosis (ALS)? 1. Electromyogram (EMG). 2. Muscle biopsy. 3. Serum creatine kinase ( CK ) 4. Pulmonary function test.
2. Biopsy confirms changes consistent with atrophy and loss of muscle fiber, both characteristics of ALS
What would a nurse assess as the initial symptoms of Parkinson's disease? 1. Akinesia 2. Aspiration of food 3. Forgetfulness 4. Pill rolling tremors
4. Early symptoms of Parkinson's disease include course resting tremors of the fingers and thumb, also known as pill rolling movements. The other choices occur later in the disease process
Which action should a nurse include in the plan of care for a client who had bacterial meningitis? 1. Restraining the client in bed 2. Increasing fluid intake 3. Keeping client in a flat supine position 4. Reducing the clients environmental stimuli
4. The meninges ate inflamed and easily irritated by sensory input. For this reason environmental stimulation should be kept to a minimum to avoid causing seizures
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D,W at 100 mL/hr. 4. Complete a neurological assessment.
4. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side-lying position. B. Document the duration of the seizure. C. Reorient the client to the environment. D. Provide client hygiene.
A. The greatest risk to the client is aspiration during the postictal phase. Priority intervention is to keep the client in a side lying position so secretions can drain from the mouth keeping the airway patent
A nurse is assessing the ICP of a patient with head trauma. The nurse would compare the clients assessment data with which normative value for ICP? 1. 0 to 15 mm Hg 2. 25 to 35 mm Hg 3. 45 to 60 mm Hg 4. 80 to 120 mm Hg
1. A normal ICP rating is 0 to 15 mm Hg. Value greater than 25 represent a life-threatening condition requiring immediate intervention
A client with a head injury has a score of 5 on the Glasgow coma scale. The nurse interprets this to mean that the client: 1. Is unresponsive and comatose 2. Is alert and oriented 3. Respond appropriately to come out 4. Is awake but lethargic and drowsy
1. A score of seven or less indicates the client is in a coma. The lower the score, the more serious the clients condition.
Which client would the nurse identify as being MOST AT RISK for experiencing a cerebrovascular accident (CVA)? 1. A 55-year-old African American male 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female
1. African Americans have twice the rate of CVS has Caucasians and men have a higher incidence than women. African-Americans also suffer more extensive damage from a CVA then do people of other cultural groups
The intensive care nurse is caring for the client who has had intracranial surgery. Which interventions should the nurse implement? Select all that apply 1. Assess for deep vein thrombosis. 2. Administer intravenous anticoagulant. 3. Monitor intake and output 4. Apply warm compresses to the eyes. 5. Perform passive range-of-motion exercises.
1. Assessing for deep in thrombosis, which is a complication of immobility, would be appropriate for this client 3. Monitoring of intake and output helps to detect possible complications of the pituitary gland, which include diabetes insipidus and syndrome of inappropriate antidiuretic hormone. 5. The nurse does not want the client to be active and possibly increase intracranial pressure, therefore, the nurse should perform passive range of motion for the client
Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply. 1. Position the client with the head of the bed up 30 degrees. 2. Cluster activities of care. 3. Suction the client every three (3) hours. 4. Administer soapsuds enemas until clear. 5. Place the client in Trendelenburg position.
1. Elevating the head of the bed 30° will decrease intracranial pressure by using gravity to drain cerebrospinal fluid 2. Minimizing disturbing the client and allowing rest in between activities will decrease ICP
What is the primary expected outcome when mannitol is a minister to a client with increased intracranial pressure? 1. Reduced intracranial pressure 2. increased urine output 3. Decreased blood pressure 4. Increased intracranial perfusion
1. Mannitol is an osmotic diuretic that increases osmotic pressure in the renal tubules. This causes an increased uptake of water and increase diuresis, which specifically helps to relieve cerebral edema, thereby decreasing intracranial pressure
The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? 1. Note the first thing the client does in the seizure 2. Assess the size of the clients pupil. 3. Determine if the client is in continent of urine or stool. 4. Provide the client with privacy during the seizure.
1. Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether the beginning of the seizure was observed.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication
1. The nurse would anticipate an oral anticoagulant, such as warfarin (Coumadin),to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA.
The client is prescribed phenytoin (Dilantin), anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? 1. "I will brush my teeth after every meal" 2. "I will check my Dilantin level daily'' 3. ''My urine will turn orange while on Dilantin. 4. "I won't have any seizures while on this medication."
1. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gungival hyperplasia, which is a common occurrence in clients taking Dilantin
The nurse is planning care for a 65 year old male client who had a CVA with residual expressive aphasia. The most appropriate expected outcome for this client would be for the client to: 1. Verbalize plans for rehabilitation 2. Demonstrate alternative communication techniques 3. Manipulate the environment to his satisfaction 4. Express understanding that aphasia is permament
2. Clients with expressive aphasia required teaching in encouragement to use alternative techniques of communication to meet their needs known and interact with others
The client diagnosed with Parkinson's disease is being admitted with a fever and patchy infiltrates in the lung field on chest x-ray. Which clinical manifestations would explain this assessment data? 1. Mask like facies and shuffling gait 2. Difficulty swallowing and immobility 3. Still rolling her fingers and flat affect 4. Lack of arm swing and Bradykinesia
2. Difficulty swallowing places the client at risk for aspiration. Immobility predispose the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications.
Which statement best describes the scientific rationale for alternating a non-narcotic antipyretic and a nonsteroidal anti-inflammatory drug every two hours to a female client diagnosed with bacterial meningitis? 1. This regimen helps to decrease the purulent exudate surounding the meninges 2. These medications will decrease intracranial pressure and brain metabolism 3. These medications will increase the clients memory and orientation 4. This will help prevent a yeast infection secondary to antibiotic therapy
2. Fever increases cerebral metabolism and intracranial pressure. Therefore, measures are taken to reduce body temperature as soon as possible and alternating Tylenol and Motrin would be appropriate
A nurse understands the importance of anticonvulsant medications being taken in the prescribed amount at the prescribed time. With this in mind, client client compliance would be measured by: 1. Asking the client when the anticonvulsant medication is being taken 2. Monthly blood test for serum levels of the anticonvulsant medication 3. A written record of the time and duration of seizure activity 4. Weekly urine specimens to detect excretion of the anticonvulsant medication
2. If medications are taken in the prescribed amount and at the prescribed times, therapeutic levels will likely demonstrate compliance
A client is suspected to have meningitis. During assessment the nurse places the client supine with the thigh flexed towards the abdomen and the knee at a 90° angle to the thigh. When the nurse extends the lower leg, the client complains of extreme pain in the low back area. These findings most accurately describe: 1. Homan sign 2. Kernig's sign 3. Nuchal rigidity 4. Brudzinski's sign
2. It is elicited when the client complains of pain in the lower back with resistance to straightening the leg. This occurs when the leg is extended while the thighs flexed towards the abdomen
The nurse is assessing a client experiencing motor loss as result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family
2. The most common motor dysfunction of a CVA is paralysis on one side of the body, hemiplagia; in this case with left sided CVA , the paralysis would affect the right side. ataxia is an impaired ability to coordinate movement
The client newly diagnosed with Parkinson's Disease (PD) asks the nurse, "Why can't I control these tremors?" Which is the nurse's best response? 1. "You can control the tremors when you learn to concentrate and focus on the cause." 2. "The tremors are caused by a lack of the chemical dopamine in the brain; medication may help." 3. "You have too much acetylcholine in your brain causing the tremors but they will get better with time." 4. "You are concerned about the tremors? If you want to talk I would like to hear how you feel."
2. This is cause of the tremors, cogwheel motion of movement, and Bradykinesia, and so forth. It is also in layman's terms that the client can understand and provide some measure of hope that something can be done without giving false reassurance
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA) 2. Discuss the precipitating factors that caused the symptoms 3. Schedule for a STAT computed tomography (CT) scan of the head 4. Notify the speech pathologist for an emergency consult.
3. A CT scan will determine if a client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is hemorrhagic or an ischemic accident and guide treatment
The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly? 1. Alzheimer's disease. 2. Parkinson's disease (PD). 3. Cerebral Vascular Accident (CVA, stroke). 4. Brain atrophy due to aging.
3. A CVA is the leading cause of seizures in the elderly. Increased intracranial pressure associated with the stroke can lead to seizures
The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis? 1. Positive Babinski's sign and peripheral paresthesia 2. Negative Chvostek's sign and facial tingling 3. Positive Kernig's sign and nuchal rigidity. 4. Negative Trousseau's sign and nystagmus.
3. A positive Kernig's sign, client unable to extend leg when lying flat, and nuchal rigidity, stiff neck, are signs of bacterial meningitis, occurring because the meninges surrounding the brain and spinal column are irritated
The client diagnosed with Parkinson's disease is being discharged on carbidopa/levodopa, Sinemet, and antiparkinsonian drug. Which statement is the scientific rationale for combining these medications? 1. There will be fewer side effects with this combination then with carbidopa alone 2. Dopamine D requires the presence of both of these medications to work 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood brain barrier to treat Parkinson's disease
3. Carbidopa enhances the effects of levodopa by inhibiting decarboxylase in the periphery, thereby making more levodopa available to the central nervous system. Simemet is the most effective treatment for Parkinson's disease
A nurse assesses a comatose, head injured client and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. Which of the following describes these findings? 1. Stroke 2. Epeptic seizure 3. Decorticate posturing 4. Decerebrate posturing
3. Decorticate posturing, described as flexion of the arms, wrists, fingers, and adduction of the upper extremities, indicates the primary motor areas of the sensorimotor cortex, both anterior & posterior, have damage.
The client who just had a three (3)-minute seizure has no apparent injuries and is o to name, place, and time but is very lethargic just wants to sleep. Which intervention should the nurse implement? 1. Perform a complete neurological assessment 2. Awaken the client every 30 minutes. 3. Turn the client to the side and allow the client to sleep. 4. Interview the client to find out what caused the seizure.
3. During the postictal (after seizure) phase, the client is very tired and should be allowed to rest quietly. Placing the client on the side will help prevent aspiration and maintain a patent airway.
A 22-year-old male is admitted to the emergency department with a closed head injury. He is awake but lethargic, and his baseline vital signs include a blood pressure of 120/80, pulse of 78, respirations of 20. Two hours later the nurse reassesses the client which Nursing data would indicate deterioration of his condition? 1. Client is sleeping, but awakens to painful stimuli 2. BP 110/80, pulse 78, & respirations 20 3. BP 160/74, pulse 53, & respirations 10 4. Client states he does not remember what happened
3. Late signs of increased intracranial pressure include an increased systolic BP and decreasing diastolic BP (widening pulse pressure), bradycardia, and decreased respirations. Client also may display a decreased level of consciousness and or seizures. The symptoms represent Cushing's Triad and require immediate interventions
A nurse is caring for a 30-year-old client with multiple sclerosis who is prescribed medication to alleviate the major symptoms of this disease. Which drug classification with the nurse most expect to be used to treat MS? 1. Narcotic analgesic 2. Anticholinesterase 3. Muscle relaxants 4. Antihypertensives
3. MS causes muscle spasticity as loss of the myelin sheath progresses. Muscle relaxers decrease the spasms
The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first? 1. Set the ventilator to hyperventilate the client in preparation for suctioning. 2. Assess the client's lung sounds and check for peripheral cyanosis. 3. Turn the client to the side to allow the secretions to drain from the mouth 4. Suction the client using the in-line suction, wait 30 seconds, and repeat.
3. Secretions can drain if the client is turned to the side unless the secretions are too heavy. The first action is to attempt to relieve the situation without increasing the ICP even further
The wife of the client diagnosed with meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? 1. "There is bleeding into his brain causing irritation of the meninges." 2. "A virus has infected the brain and meninges, causing inflammation." 3. "It is a bacterial infection of the tissues that cover the brain and spinal cord." 4. "It is an inflammation of the brain parenchyma caused by a mosquito bite
3. Septic meningitis refers to meningitis caused by bacteria. The most common form of bacterial meningitis is caused by the Neisseria meningitis bacteria
A nurse is caring for a client who had a TIA. Client's spouse questions the nurse about the significance of this condition. The nurse should explain that a TIA is: 1. Usually neurological damaging 2. A signal of progressive brain damage 3. Generally a warning of an impeding stroke 4. Nothing to be concerned about because it is not a stroke
3. TIAs are a warning of an impeding stroke of CVA. They may occur hours or days before
The client is scheduled for an electroenceph- alogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement? 1. Tell the client to take any routine antiseizure medication prior to the EEG 2. Tell the client not to eat anything for eight (8) hours prior to the procedure. 3. Instruct the client to stay awake for 24 hours prior to the EEG 4. Explain to the client that there will be some discomfort during the procedure.
3. The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or flashing lights may induce a seizure.
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure (BP) of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma
3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.
A client has been diagnosed with ALS. The nurse caring for the client recognizes that a classic symptom of this disorder: 1. Dyspnea 2. Dysuria 3. Dysphagia 4. Dysreflexia
3. Weakness of the muscles of the legs that progresses to weakness in the upper extremities, dysarthria(difficulty in speech), and dysphagia (difficulty swallowing) are all classic symptoms of ALS
The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first? 1. Administer the medication in pudding. 2. Check the client's armband 3. Crush the tablet and dissolve in juice. 4. Have the client sip some water
4. Asking the client to sip some water assesses the clients ability to swallow, which is a priority when placing anything in the mouth of a client who has had a stroke
A nurse notes that the physician has updated the orders for a client who has had a stroke by changing the medication route from parenteral to oral. Before administering the oral medications, it would be most important for the nurse to assess which cranial nerves? 1. Facial and Vagus 2. Trigeminal and Vagus 3. Trigeminal and hypoglossal 4. Glossopharyngeal and Vagus
4. Cranial nerves IX and X control swallowing and the gag reflex. The nurse message says the gag reflex before administering oral medications or feedings, to prevent the risk of aspiration
Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? 1. Standard precautions 2. Airborne precautions 3. Contact precautions 4. Droplet precautions
4. Droplet cautions are respiratory precautions use for organisms that have limited span transmission. Precautions including staying at least 4 feet away from the client or wearing a standard isolation mask and gloves when coming in close contact with the client. Clients are in isolation for 24 to 48 hours after initiation of antibiotics
The nurse is admitting a client with a diagnosis of Parkinson's disease. Which assessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention 2. Muscle weakness in the upper extremities and ptosis 3. Exaggerated arms swinging and scanning speech 4. Mask like facies and a shuffling gait
4. Mask like facies and shuffling gait are two clinical manifestations of Parkinson's disease
The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority? 1. Assess lung sounds. 2. Assess the six cardinal fields gaze 3. Assess apical pulse 4. Assess level of consciousness
4. Meningitis directly affects the clients brain. Therefore, assessing the neurological status would have priority for this client
A right handed client who is recovering from a CVA continues to experience parethesia in the right arm and hand that may be permanent. The most appropriate nursing intervention would be to instruct the client: 1. Maintain the arm in a dependent 2. Soak the arm in lukewarm water twice a day 3. Continue to use the arm and hand as much as possible 4. Begin using the other arm as the dominant limb
4. Paresthesia involves decrease in station in an area of the body, manifesting with numbness and tingling. The client should avoid using this body part as the dominant extremity, because decrease sensation will make the client more prone to injury and rehabilitation failure. This condition may be permanent. An important part of rehabilitation is to increase capability with the opposite limb.
The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom
4. Raising the toilet seat is modifying the home and addresses the clients weakness and being able to sit down and get up without straining muscles or requiring lifting assistance from the wife
What is the nursing action of highest priority to be taken with a client who experiences a generalized tonic clonic seizure? 1. Insert a tongue bleed between the teeth 2. Restrain the upper and lower extremities 3. Control the head movements 4. Protect the head and extremities
4. Staying with a client right protection of the head and extremities is the most important nursing care activity for a client experiencing a generalized tonic clonic seizure.
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? 1. Push aside any furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the client to the floor.
4. The client should not remain in the chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities.
A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply) A Impulse control dificulty B. Left hemiplegia C. Loss of depth perception D. Aphasia E. Lack of situational awareness
A. A client who has experienced a right hemispheric stroke will exhibit impulse control difficulty, such as the urgency to use the restroom B. A client who has experienced a right hemispheric stroke will exhibit left sided hemiplegia C. A client who has experienced a right hemispheric stroke will experience a loss in depth perception E. A client who is experienced a right hemispheric stroke will demonstrate a lack of awareness of surroundings
A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (Select all that apply.) A. Areas of paresthesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia
A. Areas of loss of skin sensation are a finding of a client who has MS B. Nystagmus is a finding of a client who has MS E. Ataxia occurs in the client who has MS as muscle weakness develops and there is loss of coordination
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) A. Speak to the client at a slower rate. B. Assist the client to use flash cards with pictures. C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time
A. Client to a global aphasia have difficulty with speaking at understanding speech. One strategy that can enhance client understanding is speaking to the client at a slower rate B. One strategy that can enhance understanding is the use of alternate forms of communication, such as flashcards with pictures or computer E. One strategy that can enhance understanding is giving instructions one step at a time
A nurse is teaching a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include in the teaching? A. Rise slowly when standing. B. Expect urine to become dark-colored C. Avoid foods containing tyramine D. Report any skin discoloration.
A. Orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. Therefore, rising slowly when standing up will decrease the risk of dizziness and lightheadedness
A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Have suction equipment available for use. B. Feed the client thickened liquids. C. Place food on the unaffected side of the client's mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed
A. Suction equipment should be available in case of choking and aspiration B. The client should be given liquids that are thicker than water to prevent aspiration C. Placing food on the unaffected side of the clients mouth will allow her to have better control of the food and reduce the risk of aspiration E. The client should be taught to flex her neck, tucking the chin down and under to close the epiglottis during swallowing
A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (Select all that apply.) A. Implement Seizure precautions. B. Perform neurological checks four times a day. C. Administer morphine for the report of neck and generalized pain. D. Turn off room lights and television. E. Monitor for impaired extraocular movements. F. Encourage the client to cough frequently
A. The client is at risk for seizures due to possible increased ICP. Therefore, the nurse should implement seizure precautions to reduce the client's risk for injury D. The nurse should turn off room lights and the television because they can increase neuron stimulation and cause a seizure when a client is at risk for increased ICP. E. The nurse should monitor for impaired extraocular movements because this finding can indicate increased ICP.
The nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy B. Ease the client to the floor if standing C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.
A. The nurse should implement privacy to minimize the client's embarrassment B. The nurse should ease the client to the floor to prevent falling and injury C. The nurse should move the furniture away from the client to prevent injury D. The nurse should loosen the clients clothing to minimize restriction of movement E. The nurse should protect the clients head from injury by placing the clients head in her lap or using a pillow or blanket under the head during a seizure
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet. C. Limit looking at flashing lights D. Perform aerobic exercise. E. Limit episodes of hypoventilation F. Use of aerosol hairspray is recommended
A. The nurse should instruct the client to avoid overwhelming fatigue, which can trigger a seizure by stimulating abnormal electrical neuron activity B. The nurse should instruct the client to remove caffeinated products from the diet, which can trigger a seizure by stimulating abnormal electrical neuron activity C. The nurse should instruct the client to refrain from looking at flashing lights, which can trigger a seizure by stimulating abnormal electrical neuron activity
A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (Select all that apply.) A. Place client in supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest E. Straighten the client's flexed leg at the knee
A. The nurse should place the client in supine position when assessing for Brudzinski's sign. C. The nurse should place her hands behind the client's neck when assessing for Brudzinski's sign, in order to flex the client's neck. D. The nurse should bend the client's head toward the chest when assessing for Brudzinski's sign.
A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential raising the client's ICP? (Select apply.) A. Suction the endotracheal tube frequently B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.
B. Decreasing the noise level and restricting the number of people in the clients room can help prevent increases in ICP D. Administration of a stool softener will decrease the need to bear down (Valsalva Maneuver) during bowel movements, which can increase ICP
A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics. B. Implement droplet precautions. C. Initiate IV access. D. Decrease bright lights.
B. Implement droplet precautions. When using the urgent vs. non-urgent approach to care, the nurse determines the priority action is to initiate droplet precautions when meningitis is suspected to prevent spread of the disease to others.
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids
B. Loss of cognitive function is a manifestation associated with MS
A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria
B. Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances such as hyponatremia
A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply) A. Decreased vision B. Pill-rolling tremor of the fingers C. Shuffling gait D. Drooling E. Bilateral ankle edema F. Lack of facial expression
B. The client who has Parkinson's disease can manifest pill rolling tremors of the fingers due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult C. The client who has Parkinson's disease can manifest shuffling gait because of overstimulation of the basal ganglia by acetylcholine making controlled movement difficult D. The client who has Parkinson's disease can manifest drooling because of overstimulation of the basal ganglia by acetylcholine making controlled movement of swallowing secretions difficult F. The client who has Parkinson's disease can manifest a lack of facial expressions due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult
A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Monitor for bradycardia. B. Provide an emesis basin at the bedside. C. Administer antipyretic medication. D. Perform a skin assessment. E. Keep the head of the bed flat.
B. The nurse should provide an emesis basin at the bedside because a client who has meningitis can have nausea and vomiting C. The nurse should plan to administer antipyretic medication for fever to a client who has meningitis D. The nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meningcoccal meningitis
A nurse is developing a plan of care for a client who has stage IV Parkinson's for the nutritional needs of the disease. Which actions should the nurse include in the plan of care? (Select all that apply) A. Provide three large balanced meals daily. B. Record diet and fluid intake daily. C. Document weight every other week. D. Place the client in Fowler's position to eat. E. Offer nutritional supplements between meals.
B. The nurse should record the clients diet and fluid intake daily to assess for dietary needs and maintain adequate nutrition and hydration E. The nurse should offer nutritional supplements between meals to maintain the clients weight
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception
C. A client who experienced a left hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia
A nurse is caring for a client who displays signs of stage III Parkinson's disease. Which of the following actions should the nurse include in the plan of care? A. Recommend a community support group. B. Integrate a daily exercise routine. C. Provide a walker for ambulation. D. Perform ADLs for the client.
C. The client should use a walker for ambulation because movement slows down significantly and gait disturbances occur
A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce the risk of respiratory infection. B. The vaccine is administered in a series of four doses C. The vaccine is recommended for adolescents before starting college. D. The vaccine is initially given at 2 months of age.
C. The nurse should identify that the vaccine is recommended for adolescents prior to starting college due to the increased risk for infection in communal living facilities
A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day D. Provide a urine sample to determine therapeutic levels of the medication.
C. The nurse should instruct the client to take phenytoin the same time every day to enhance effectiveness
A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors. B. "This medication will help with your bladder function." C. "This medication may cause your skin to bruise easily." D. "This medication may cause you to experience weakness."
D. Baclofen is an antispasmotic medication that is given to clients with MS to treat muscle spasms. An adverse affect of this medication is weakness, as well as dizziness. The nurse should instruct the client to monitor for these findings, as they can lead to impaired safety. The client should be instructed not to discontinue baclofen abruptly
A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse? A. Teach the client to walk more quickly when ambulating. B. Complete passive range-of-motion exercises daily C. Place the client on a low-protein, low-calorie diet. D. Give the client extra time to perform activities.
D. Bradykinesia is abnormally slowed movement and is seen in clients who have PD. The client should be given extra time to perform activities and should be encouraged to remain active