Neuro Quiz 4 & 5 ATI

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A. A change in the Glasgow Coma Scale score from 13 to 11 B. Diplopia C. A drop in heart rate from 76 to 70/min D. Ataxia

A. A change in the Glasgow Coma Scale score from 13 to 11

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.) A. Administer furosemide. B. Administer warfarin. C. Implement a low-sodium diet. D. Measure the client's abdominal girth. E. Encourage weight lifting during physical therapy.

A. Administer furosemide. C. Implement a low-sodium diet. D. Measure the client's abdominal girth.

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include? A. Both are inflammatory B. Both begin in the rectum C. Both manifest fistula formation D. Both require frequent surgery

A. Both are inflammatory

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform? A. Complete a neurological check. B. Administer the prescribed PRN antihypertensive medication. C. Increase the client's fluid intake. D. Hold the client's evening dose of digoxin.

A. Complete a neurological check.

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? A. Decrease the client's fluid intake. B. Increase the client's saturated fat intake. C. Increase the client's sodium intake. D. Decrease the client's carbohydrate intake.

A. Decrease the client's fluid intake.

A nurse is reviewing the laboratory results of a client who has liver failure with ascites and is receiving spironolactone. Which of the following findings should the nurse expect? A. Decreased sodium level B. Decreased phosphate level C. Decreased potassium level D. Decreased chloride level

A. Decreased sodium level

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? A. Gallstones B. Hypolipidemia C. COPD D. Diabetes mellitus

A. Gallstones

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client? A. Soy milk B. Cheddar cheese C. Low-fat yogurt D. Cottage cheese

A. Soy milk

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client? A. "Do have a history of chronic alcohol abuse?" B. "Have you had a recent influenza infection?" C. "Have traveled overseas recently?" D. "Are you taking a multivitamin?"

B. "Have you had a recent influenza infection?"

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide? A. Phenytoin turns urine blue. B. Alcohol increases the chance of phenytoin toxicity. C. Avoid flossing the teeth to prevent gum irritation. D. Take an antacid with the medication if indigestion occurs.

B. Alcohol increases the chance of phenytoin toxicity.

A nurse is preparing to administer a dose of lactulose to a client who has cirrhosis. The client states, "I don't need this medication. I am not constipated." The nurse should explain that in clients who have cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstream? A. Glucose B. Ammonia C. Potassium D. Bicarbonate

B. Ammonia

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? A. Transient ischemic attack (TIA) B. Hemorrhagic stroke C. Thrombotic stroke D. Embolic stroke

B. Hemorrhagic stroke

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading B. Inability to recognize his family members C. Right hemiparesis D. Aphasia

B. Inability to recognize his family members

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? A. Place the client in protective isolation. B. Minimize environmental stimuli. C. Elevate the head of the client's bed 45°. D. Limit the client's ambulation to once a day.

B. Minimize environmental stimuli.

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority? A. Recommend that the partner place the client in a long-term care facility. B. Suggest that the partner see a counselor to help him cope with his exhaustion. C. Ask the partner to talk about his difficulties in caring for the client. D. Tell the partner to call a family meeting to get help.

C. Ask the partner to talk about his difficulties in caring for the client.

15.A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? A. Include foods high in starch and proteins. B. Include foods high in fiber. C. Avoid foods high in fat. D. Avoid foods high in sodium.

C. Avoid foods high in fat.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? A. Pruritus B. Hypertension C. Bradykinesia D. Xerostomia

C. Bradykinesia

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? A. Encourage brief exercise before meals to promote appetite. B.Place food in the affected side of the mouth. C. Encourage the client to take small bites. D. Place the client with the head reclined back to facilitate swallowing.

C. Encourage the client to take small bites.

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? A. Administer diuretics. B. Restrict the client's intake of fluids. C. Reduce the client's intake of protein. D. Administer vitamin K.

C. Reduce the client's intake of protein.

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? A. "Wear an eye patch on the right eye at all times." B. "Plan to relax in a hot tub spa each day." C. "Engage in a vigorous exercise program." D. "Implement a schedule to include periods of rest."

D. "Implement a schedule to include periods of rest."

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? A. "Insert a padded tongue blade into the client's mouth." B. "Restrain the client." C. "Place the client on his back." D. "Move objects away from the client."

D. "Move objects away from the client."

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? A. Decreased auditory and visual acuity B. Decreased display of emotions C. Personality traits that are opposite of original traits D. Forgetfulness gradually progressing to disorientation

D. Forgetfulness gradually progressing to disorientation

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness

D. Restlessness

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands. B. The client is unable to make vocal sound. C. The client is unconscious. D. The client opens his eyes when spoken to.

D. The client opens his eyes when spoken to.

A nurse is caring for a client who has Crohn's disease. Which of the following food choices would follow the recommended diet for clients who have Crohn's disease? A. Vanilla milkshake B. Buttered popcorn C. Tossed green salad D. Toast with jelly

D. Toast with jelly