neuro prepu

A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. Encourage the client to increase his/her intake of water and juice. Assist the client out of bed and into the chair for meals. Instruct the client to tuck his/her chin towards their chest when swallowing. Request a swallowing assessment by a speech therapist before the client's discharge. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

B,C

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Instruct the client to lie on the bed when eating Offer liquids frequently, in large quantities Help the client sit upright when eating and feed slowly Allow optimum physical activity before meals to expedite digestion

c

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Musculoskeletal Integumentary Hepatic Renal

d

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Use one long sentence to say everything that needs to be said. Keep the television on while she speaks. Talk in a louder than normal voice. Face the client and establish eye contact.

d

The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for signs and symptoms of cardiac insufficiency. signs of relapse. signs of improvement in the patient's condition. renal complications related to acyclovir therapy.

d

The primary arthropod vector in North America that transmits encephalitis is the tick. horse. mosquito. flea.

d

A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? Cerebral cortex Temporal lobe Central sulcus Penumbra region

D

A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications? Placement of a feeding tube Placement of a urinary catheter Placement of a colostomy tube Placement of a tracheostomy tube

a

A nurse is caring for a client diagnosed with Guillain-Barré syndrome. The client states, "It's getting harder to take a deep breath." Which action by the nurse is most appropriate? Call the physician and prepare for intubation. Explain the progression of the syndrome. Assess lung sounds. Encourage the client to cough.

a

The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? Using the incentive spirometer as prescribed Maintaining the client on bed rest Providing aids to compensate for loss of vision Assessing frequently for loss of cognitive function

a

While assessing a newly admitted client, the nurse identifies impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest? Ineffective health maintenance Impaired physical mobility Disturbed sensory perception: Kinesthetic Ineffective role performance

b

he nurse is caring for a client with aphasia. Which action will the nurse take when communicating with the client? Select all that apply. Pause between phrases Use gestures when talking Face the client when talking Talk over the television volume Speak in a normal tone of voice

A,B,C,E

A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? Anticipate the client will exhibit some degree of expressive or receptive aphasia. Place the wheelchair on the client's left side when transferring him into a wheelchair. Provide close supervision because of the client's impulsiveness and poor judgment. Support the right arm with a sling or pillow to prevent subluxation.

C

Which are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply. Pain Fatigue Spasticity Aphasia Depression Numbness

a,b,c,,e,f

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply. Decreased glucose Increased protein Increased white blood cells Decreased protein Increased glucose

a,b,c

The nurse is assessing a male client with multiple sclerosis (MS). What education would the nurse provide to assist the client in managing this disease? Select all that apply. Avoidance of hot temperatures Treatment of any episodes of depression Effective treatment of anemia Recommend bone mineral density testing Participation in occupational therapy

a,b,c,e

A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply. respiratory distress increasing ICP seizure activity difficulty swallowinga,d

a,d

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. intracranial hemorrhage Ischemic stroke Age 18 years or older Systolic BP less than or equal to 185 mm Hg Major abdominal surgery within 10 days

a,e

A client is diagnosed with an ischemic stroke. For which reason(s) would the nurse question the use of tissue plasminogen activator (tPA) for this client? Select all that apply. Platelet count 95,000/mm3 Prothrombin time 10 seconds Systolic blood pressure 198 mm Hg Diastolic blood pressure 120 mm Hg Received low-molecular weight heparin injections twice a day

A,C,D,E

The nurse is caring for a client recovering from a stroke. Which action will the nurse take to prevent adduction of the client's affected shoulder? Select all that apply. Place a pillow in the axilla area. Position the arm parallel to the torso. Situate the arm in a slightly flexed position. Put a rolled towel in the affected hand. Position the wrist higher than the elbow.

a, e

The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response? "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." "I know you understand that nerve cells do not remyelinate, so the health care provider is the best one to answer your question." "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."

a