Neurologic disorders

a nurse is collecting data from a client who has a traumatic head injury to determine motor function response. which of the following client responses to painful stimuli is within normal limits? 1 pushes the painful stimulus away 2 extends the body part toward the stimulus 3 shows no reaction to the painful stimulus 4 flexes the upper and extends the lower extremities

1 pushes the painful stimulus away

a nurse is reinforcing teaching with a class of newly licensed nurses about preparing clients for surgery. which of the following instructions should the nurse include in the teaching? 1 secure a client's body piercings with tape 2 allow a client to leave dentures in his mouth 3 remove a client's hearing aid 4 ask a client to remove contact lenses

4 ask a client to remove contact lenses The nurse should ask a client to remove contact lenses to prevent damage to the client's eyes during the surgery. Secure a client's body piercings with tape. The nurse should ask the client to remove all jewelry and body piercings to prevent injury caused by an electrical burn from the electrocautery equipment. A wedding ring may be secured with tape if it cannot be removed. Allow a client to leave dentures in his mouth. The nurse should remove dentures from a client, unless otherwise instructed, to prevent damage to the dentures during endotracheal intubation. Remove a client's hearing aid. The nurse should allow a client to leave a hearing aid in place so that the client can hear immediately postoperative the surgery. The nurse should document the placement of the hearing aid on the client's chart and notify the surgical team.

a nurse is collecting data from a client who was involved in a motor-vehicle crash. which of the following techniques should the nurse use to test for corneal reflexes? 1 examine the eye with a penlight 2 instill drops of dye into the eye 3 visualize the red reflex of the eye 4 lightly touch the eye with a wisp of cotton

4 lightly touch the eye with a wisp of cotton Examine the eye with a penlight. The nurse should examine the eye with a penlight to determine pupil reaction. Instill drops of dye into the eye. The nurse should instill drops of dye into the eye to determine if there are foreign bodies in the eye. Visualize the red reflex of the eye. The nurse should examine the red reflex of the eye to inspect the retina. Lightly touch the eye with a wisp of cotton. The nurse should lightly touch the cornea with a wisp of cotton. Corneal reflexes result from the loss of the ability to blink, due to a head injury or stroke.

a nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. which of the following statements should the nurse include in the teaching? 1 tonometry is performed to evaluate peripheral vision 2 this test will diagnose the type of your glaucoma 3 tonometry will allow inspection of the optic disc for signs of degeneration 4 this test will measure the intraocular pressure of the eye

4 this test will measure the intraocular pressure of the eye A tonometry examination provides a precise and simple way to measure intraocular pressure. This is a component of a comprehensive eye examination and is crucial for clients who have glaucoma or who are at high risk for developing intraocular hypertension. "Tonometry is performed to evaluate peripheral vision." The nurse should identify the visual field test as determining the loss of peripheral vision. "This test will diagnose the type of your glaucoma." The nurse should identify gonioscopy as the examination used to differentiate between open-and and angle-closure glaucoma. An instrument, the gonioscope, is used to measure the depth of the anterior chamber. "Tonometry will allow inspection of the optic disc for signs of degeneration." The nurse should identify fundoscopy as the examination performed to assess the color of the eye's fundus as well as the optic disc itself.

a nurse is reinforcing preoperative teaching with a client who is scheduled for cataract surgery. which of the following statements should the nurse make? 1 you should report bloodshot eyes on the day of surgery 2 you should apply warm compresses to the eye 3 times daily 3 you should expect bro pain for 3 days after the procedure 4 you should expect your vision to improve within 2 weeks of the surgery

4 you should expect your vision to improve within 2 weeks of the surgery

a nurse is reinforcing discharge teaching with a client following a cataract extraction. which of the following should the nurse include in the teaching? 1 avoid bending at the waist 2 remove the eye shield at bedtime 3 limit the use of laxatives if constipated 4 seeing flashes of light in an expected finding following extraction

avoid bending at the waist

A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? A. "The bright light in this room is really bothering me." B. " My eye really itches, but I`m trying not to rub it." C. " It`s really hard to see with a patch on one eye." D. "I need something for the horrible pain in my eye."

D. "I need something for the horrible pain in my eye."

a nurse is contributing to the plan of care for a client who is having headaches following the administration of a spinal anesthetic during surgery. which of the following interventions should the nurse include in the plan of care? Encourage increased intake of fluids. Encourage increased physical activity. Maintain the client in high Fowler's position ​Apply an ice bag at the injection site of the spinal anesthetic

Encourage increased intake of fluids. Increased oral fluid intake promotes increases intracranial pressure which may relieve spinal headaches.

a nurse is caring for a client who reports feeling anxious about abdominal surgery the next day. which of the following actions should the nurse plan to take?

Encourage the client to verbalize his concerns.

A nurse is reinforcing teaching with a client who reports having migraine headaches. The nurse should identify that the client can use which of the following herbal supplements prophylactically to manage migraine headaches? ​Valerian Feverfew ​Ginkgo biloba ​St. John's wort

Feverfew Clients can use feverfew prophylactically to decrease how often migraines occur and the severity of symptoms such as nausea, photophobia, and pain. This action might result from preventing vasoconstriction in the brain and suppressing release of serotonin from platelets and leukocytes.

A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching? Temporary, reversible loss of brain function Forgetfulness gradually progressing to disorientation Sleeping more during the day than nighttime Hyper vigilant behaviors

Forgetfulness gradually progressing to disorientation Dementia usually appears first as forgetfulness. Loss of functioning progresses slowly from impaired language skills and difficulty with ordinary, daily activities to severe memory loss and complete disorientation with withdrawal from social interaction.

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I? Have the client identify specific smells. Check the client's visual acuity using a Snellen chart. Whisper in one of the client's ears while occluding the other. Observe for facial symmetry while the client smiles.

Have the client identify specific smells. The nurse should have the client identify specific smells, such as coffee or peppermint, testing each nostril separately, when checking cranial nerve I, the olfactory nerve.

A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately? Increased anxiety Anorexia Blurred vision Disorientation

Increased anxiety Lorazepam is a benzodiazepine, which is a CNS depressant. Increased anxiety is a manifestation of paradoxical excitement, which can occur in older adults. In the presence of paradoxical excitement, the medication should be withdrawn.

A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) Instruct the client to cough and deep breathe every 4 hr. Have the client sit at the bedside prior to getting up. Remove compression stockings once per day. Provide pain medications around the clock for the first 48 hr. Encourage intake of foods high in carbohydrates.

Instruct the client to cough and deep breathe every 4 hr is incorrect. The nurse should encourage the client to cough and deep breathe every 1 to 2 hr while awake to decrease the risk of atelectasis and pneumonia. Have the client sit at the bedside prior to getting up is correct. Sitting at the bedside prior to rising reduces the risk of the client experiencing orthostatic hypotension. Remove compression stockings once per day is incorrect. Compression stockings should be removed at least once per shift in order to perform a through skin assessment. Provide pain medications around the clock for the first 48 hr is correct. Relieving pain allows the client to better participate in postoperative therapies and minimize risks associated with surgery. Encourage intake of foods high in carbohydrates is incorrect. Once the client is able to tolerate oral intake, the nurse should encourage consumption of foods high in protein and vitamin C to promote wound healing.

a nurse is collecting data from a client who has open-angle glaucoma. which of the following findings should the nurse expect? Loss of peripheral vision Headache Halos around lights Discomfort in the eyes

Loss of peripheral vision The nurse should expect to find the client experiencing a gradual loss of peripheral vision with a narrowing of the visual field with open-angle glaucoma. Headache Headache is associated with acute angle-closure glaucoma. Halos around lights A halo around lights with blurred vision is associated with acute angle-closure glaucoma. Discomfort in the eyes Discomfort in the eyes is associated with acute angle-closure glaucoma.

a nurse is assisting in planning care for a client who has a head injury and is in a halo traction device. which of the following actions should the nurse recommend for the plan of care? Monitor the client for elevated temperature. Loosen the pins of the device if the client experiences headaches. Instruct the client to sleep without a pillow under the head. Remind the client that weights must hang freely.

Monitor the client for elevated temperature. Clients who have cervical fractures may be placed in a halo fixation device. The device is secured with four screws inserted directly into the client's skull. This promotes cervical alignment. The metal halo ring may be attached to a vest when the spine is stable. This allows for increased mobility. Common complications include loose pins, local infection, and scarring. More serious complications include osteomyelitis, subdural abscess, and instability. The nurse should monitor vital signs for signs of infection such as fever and purulent drainage from pin sites. An elevated temperature would indicate an infectious process. The nurse should notify the provider should this occur.

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII? Observe for facial symmetry while the client smiles. Have the client identify specific smells. Check the client's visual acuity using a Snellen chart. Whisper in one of the client's ears while occluding the other.

Observe for facial symmetry while the client smiles. The nurse should ask the client to smile, then observe for symmetry of facial movements when checking cranial nerve VII, the facial nerve.

A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take? Engage the client in a small group activity. Offer the client high-calorie foods and fluids frequently. Play loud music for the client in her room. Instruct the client to avoid napping during the day.

Offer the client high-calorie foods and fluids frequently. Offering the client high-calorie foods and fluids is encouraged to prevent a calorie deficit due to the client's high level of physical activity.

A nurse observes another nurse performing a procedure in the incorrect sequence. The procedure does not harm the client. Which of the following actions should the nurse take first? Speak with the other nurse privately. Submit an incident report. Correct the mistake independently. Volunteer to perform the procedure next time.

Speak with the other nurse privately. The first action the nurse should take using the nursing process is to collect data from the client. The nurse has already determined that the procedure did not harm the client, so the next step is to collect data from the nurse. There might have been a reason for the way the other nurse performed the procedure, or she may simply need further information, which the nurse can provide. Using the data collection first priority-setting framework, the nurse will better know which course of action to take next.

a nurse is preparing home instructions for a client who has epilepsy. which of the following information should the nurse include in the teaching? Caffeine can help prevent seizure occurrence. Take showers rather than tub baths. Engage in exercise just prior to bedtime. Fasting can help increase the seizure threshold.

Take showers rather than tub baths. The nurse should recommend that the client take a shower rather than a tub bath to avoid drowning if the client should have a seizure while bathing.

A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take? Assign the client to a quiet room away from the nurses' station. Elevate the four side rails on the client's bed at night time. Encourage the client to rest during the day. Take the client to the bathroom on a regular schedule.

Take the client to the bathroom on a regular schedule. The nurse should take the client to the bathroom on a regular schedule to reduce the risk of the client getting out of bed, wandering at night, and falling.

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? The client can follow simple motor commands. The client is unable to make vocal sound. The client is unconscious. The client opens his eyes when spoken to.

The client opens his eyes when spoken to. The client can follow simple motor commands. The client's ability to follow commands earns a score of 6 for best motor response. The client is unable to make vocal sound. The inability of the client to make vocal sounds earns a score of 1 for best verbal response. The client is unconscious. A client who is unconscious earns a score of 1 for eye opening and a 1 for best verbal response. The client opens his eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.

A nurse is collecting data about a client's cranial nerves. Which of the following methods should the nurse use to identify a problem with cranial nerve II? Use a Snellen chart. Determine if the client's speech is hoarse. Present the client with mildly scented aromas. Ask the client to her clench teeth.

Use a Snellen chart. The nurse should use a Snellen chart to determine the presence of visual problems related to cranial nerve II, which is the optic nerve.

A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using? Guided imagery Validation Remotivation Orientation to reality

Validation The nurse is using validation therapy. In validation therapy, rather than trying to reorient the client to reality, the nurse shows respect for the client's reality and redirects the client by encouraging her to talk about her feelings.

a nurse is contributing to the plan of care for a client who has labyrinthitis. which of the following interventions should the nurse include in the plan? 1 limit fluid intake 2 monitor client's cardinal fields of vision 3 encourage ambulation 4 ensure the room is brightly lit

2 monitor client's cardinal fields of vision

a nurse is caring for a client who has alzheimer's disease and is confused. which of the following actions should the nurse take? 1 keep the television on at all times 2 hang abstract pictures on the walls 3 keep familiar personal items in client's room 4 encourage bright lightning in the room

3 keep familiar personal items in client's room A client who is confused should have familiar personal items nearby to help the client reminisce.

a nurse is reinforcing discharge teaching with a client who postoperative following a cataract extraction. which of the following statements by the client indicates an understanding of the teaching? 1. i will take a dose of aspirin if i have pain in the area of eyebrow 2 i can pick up a sack of groceries that weight 15 pounds 3 i can begin lying on my operative side 24 hours after my surgical procedure 4 i will bend at my knees if i need to pick something up off of the floor

4 i will bend at my knees if i need to pick something up off of the floor

a nurse is caring for a client who is using a patient control analgesia (pca) pump for postoperative pain management. the nurse enters the room to find the client asleep and his partner pressing the button to dispense a dose of analgesia. which of the following responses should the nurse make? 1next time you think he needs more medication, call me and ill push the button 2 its a good idea to help make sure your husband can sleep comfortably 3 why do you think your husband needs more medication when he is asleep? 4 your husband should decide when more medication is needed

4 your husband should decide when more medication is needed

a nurse is reinforcing teaching about donepezil with the family of a client who has alzheimer's disease. which of the following information should the nurse include in the teaching? 1 fainting episodes can occur 2 the medication can increase heart rate 3 administer daily in the morning 4 monitor for constipation

Fainting episodes can occur. The nurse should inform the family to monitor for syncope, which places the client at risk for falling.

A nurse in a long-term care facility is caring for an older adult client who is anxious and has trouble sleeping at night. Which of the following nursing measures should the nurse implement? Get the client ready for sleep at the same time each night. Move the client to a room next to the open nurses' station. Play the client's favorite music in the room while the client is sleeping. Encourage client to take a 1-hr nap each afternoon.

Get the client ready for sleep at the same time each night. A soothing nighttime routine can promote relaxation and rest, including providing a consistent time to go to bed and time to wake in the morning.

a nurse is collecting data from a client who has diabetes insipidus. which of the following findings should the nurse expect?

Tachycardia

a nurse is caring for a client scheduled for a bone marrow biopsy. the client expresses fear about the procedure and asks the nurse if the biopsy will hurt. which of the following responses should the nurse make? "You must be very worried about what the biopsy will show." "You'll be asleep for the whole biopsy procedure and won't be aware of what's happening." "Your provider scheduled this, so she will want to know you still have questions about the procedure." "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."

"The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." "You must be very worried about what the biopsy will show." This response is nontherapeutic because it is judgmental and does not address the information that the client is seeking. "You'll be asleep for the whole biopsy procedure and won't be aware of what's happening." This response is nontherapeutic because it discourages further communication from the client. The nurse should understand the client will not receive general anesthesia for this procedure. "Your provider scheduled this, so she will want to know you still have questions about the procedure." This response is nontherapeutic because it puts the client's concerns on hold and focuses on the provider. "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible." This response is therapeutic because it gives the client the information that she needs to cope, and reassures the client of the plan to address her comfort, and allows for further communication of concerns by the client.

a nurse is reinforcing teaching with a client about how to use a patient-controlled analgesia (PCA) pump. which of the following statements should the nurse include in the teaching?

"There is a 30 minute lock-out limit programmed on your PCA pump."

a nurse is collecting data from a client who has an epidural hematoma. which of the following manifestations should the nurse expect? 1 lucid period followed by rapid loss of consciousness after the injury occurs 2 headache and drowsiness 24 to 48 hr after injury occurs 3 neurological deficits that appear up to 2 weeks after the injure occurred 4 slowed thinking and confusion developing up to several months after injury occurred

-1 lucid period followed by rapid loss of consciousness after the injury occurs The nurse should expect the client who has an epidural hematoma to have a brief loss of consciousness followed by a lucid period. This lucid period is then followed by a rapid loss of consciousness ultimately deteriorating to a coma. Headache and drowsiness 24 to 48 hr after the injury occurs The nurse should expect the client who has an acute subdural hematoma to have a headache and drowsiness 24 to 48 hr after the injury occurs. Neurological deficits that appear up to 2 weeks after the injury occurred The nurse should expect the client who has a subacute subdural hematoma to have neurological deficits that appear up to two weeks after the injury occurs. Slowed thinking and confusion developing up to several months after the injury occurred The nurse should expect the client who has a chronic subdural hematoma to have slowed thinking and confusion developing weeks to months after the initial injury occurred.

a nurse is caring for a client who has alzheimer's disease. the nurse discovers the client entering the room of another client. who becomes upset and frightened. which of the following actions should the nurse take? Attempt to determine what the client was looking for. Explain the client's Alzheimer's diagnosis to the frightened client. Reprimand the client for invading the other client's privacy. Ask the client to apologize for his behavior.

-Attempt to determine what the client was looking for. Clients who have Alzheimer's disease frequently exhibit wandering behavior when they have an unmet need. The nurse should attempt to discover the reason for the client's wandering, which could include a need for toileting, uncontrolled pain, or searching for a familiar object. Explain the client's Alzheimer's diagnosis to the frightened client. The nurse should not reveal information about this client's diagnosis because it violates the client's rights to privacy. Reprimand the client for invading the other client's privacy. The nurse should recognize the client is confused; therefore, this action is inappropriate. Ask the client to apologize for his behavior. The nurse should recognize the client is confused; therefore, this action is inappropriate.

a nurse assisting with the care of a client who is receiving treatment following a motor vehicle crash. which of the following actions should the nurse take to determine the client's level of alertness? Check the client's eye opening in response to verbal stimuli. Check the client's pupillary response to light. Check the client's motor response to nail bed pressure. Check the client's response to questions about place and time.

-Check the client's eye opening in response to verbal stimuli. Checking the client's eye opening response to verbal stimuli is an appropriate method to check alertness. Check the client's pupillary response to light. The nurse should check the client's pupillary response to light as part of a neurological assessment, but this does not indicate the client's alertness. Check the client's motor response to nail bed pressure. The nurse should check for motor response in clients who are not alert and do not respond to verbal stimuli. Check the client's response to questions about place and time. The nurse should question the client regarding place and time to determine the client's level of orientation.

a nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. to do this, nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? Observing for facial asymmetry Checking pupillary responses to light Eliciting the gag reflex Testing visual acuity

-Checking pupillary responses to light Cranial nerve III, the oculomotor nerve, is responsible for pupillary responses to light. Indications that intracranial pressure is increasing include lethargy, decreasing consciousness, tachypnea, hypertension, bradycardia, bounding pulse, and changes in the pupils, such as a sluggish response to light and dilation of one or both pupils. Observing for facial asymmetry Cranial nerve VII, the facial nerve, is a motor nerve that controls facial symmetry. Eliciting the gag reflex Cranial nerves IX and X, the glossopharyngeal and vagus nerves, are nerves that control the gag reflex. Testing visual acuity Cranial nerve II, the optic nerve, is responsible for visual acuity.

a nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. the nurse should identify that which of the following factors can cause a myasthenic crisis? Developing a respiratory infection Taking too much prescribed medication Insufficient sleep Insufficient exercise

-Developing a respiratory infection Developing a respiratory infection The most common triggers of a myasthenic crisis is a respiratory infection as a result of not taking or taking too little of the prescribed medication. Surgery and pregnancy are also triggers. Taking too much prescribed medication Not taking or taking too little of the prescribed medication is more likely to trigger a myasthenic crisis. Taking an excess amount of medication can cause a cholinergic crisis. Insufficient sleep Although clients who have myasthenia gravis should rest and conserve energy, getting too little sleep on occasion should not trigger a myasthenic crisis. Insufficient exercise Vigorous physical activity, as from exercising excessively, can trigger a myasthenic crisis.

an acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. while performing a neurological examination, which of the following findings is the earliest indicator of the client's cerebral status? Pupil response Deep tendon reflexes Muscle strength Level of consciousness

-Level of consciousness The first action the nurse should take using the nursing process is to collect data about the client's level of consciousness, as this finding is the earliest indicator of the client's cerebral status. Pupil response The nurse should include pupil response as part of a neurological examination; however, it is not the earliest indicator of cerebral status. Deep tendon reflexes The nurse should include deep tendon reflexes as part of a neurological examination; however, it is not the earliest indicator of cerebral status. Muscle strength The nurse should include muscle strength as part of a neurological examination; however, it is not the earliest indicator of cerebral status.

a nurse is caring for a client who has a cerebral aneurysm. which following actions should the nurse take? Allow the client bathroom privileges. Monitor vital signs at least once each hour. Allow natural sunlight in the room. Encourage the client's family and friends to visit.

-Monitor vital signs at least once each hour. The nurse should monitor the client's vital signs at least once each hour to detect manifestations of increasing intracranial pressure. Allow the client bathroom privileges. The nurse should not allow the client bathroom privileges, because activity may cause a rupture of the aneurysm. Allow natural sunlight in the room. The nurse should not allow natural sunlight in to the room because the client may have photophobia. Encourage the client's family and friends to visit. The nurse should not encourage visitors, because excess stimulation could increase blood pressure, intracranial pressure, and lead to a rupture of the aneurysm.

a nurse is caring for a client who has a spinal cord injury at T-4. the nurse should recognize that the client is at risk for autonomic dysreflexia. which of the following interventions should the nurse take to prevent autonomic dysreflexia? Monitor for elevated blood pressure. Provide analgesia for headaches. Prevent bladder distention. Elevate the client's head.

-Prevent bladder distention. Autonomic dysreflexia can occur in clients who have a spinal cord injury at or above the T-6 level. Autonomic dysreflexia can occur as a result of an irritation, or stimulus to the nervous system below the level of injury. Triggers of autonomic dysreflexia include bladder distention, insertion of rectal suppository, enemas, or a sudden change in position Monitor for elevated blood pressure. Elevated blood pressure is a serious manifestation of autonomic dysreflexia. However, it is not a causative agent. Provide analgesia for headaches. A severe headache is one of the manifestations of autonomic dysreflexia. However, it is not a causative agent. Elevate the client's head. A sudden change in position can trigger autonomic dysreflexia.

a nurse is reinforcing teaching to the family of a client who has parkinson`s disease. which of the following instructions should the nurse include? 1 provide the client a cane 2 limit the client`s physical activity 3 speak loudly to the client 4 offer the client 3 large meals a day

-Provide the client a cane. The nurse's instructions should include providing the client with a cane or walker to increase stability and decrease the risk of falls. Limit the client's physical activity. The nurse's instructions should include providing an exercise program to improve mobility, alternated with periods of rest, not limiting activity. Speak loudly to the client. The nurse's instructions should include speaking clearly and in a normal tone to the client. There is no reason to speak loudly to a client with Parkinson's disease. Offer the client 3 large meals a day. The nurse's instructions should include offering the client six small meals per day to compensate for the need to eat slowly and take small bites to reduce the risk of aspiration.

a nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. which of the following actions should the nurse take? Provide a nonskid mat to reduce plate movement. Encourage the client to use her right hand when feeding herself. Remind that the client look for food on the left side of the tray. Encourage the use of wide grip utensils.

-Remind that the client look for food on the left side of the tray. The nurse's action of reminding the client to look for food on the left side of the tray will train the client to scan the tray by moving her head and eyes. This action will help to resolve the problem of homonymous hemianopsia. Provide a nonskid mat to reduce plate movement. The nurse's action of providing a nonskid mat to reduce plate movement is appropriate. However, it does not resolve the problem of homonymous hemianopsia. Encourage the client to use her right hand when feeding herself. The nurse's action of encouraging the client to use her right hand when feeding herself is appropriate. However, it does not resolve the problem of homonymous hemianopsia. Encourage the use of wide grip utensils. The nurse's action of encouraging the use of the wide grip utensils is appropriate. However, it does not resolve the problem of homonymous hemianopsia.

a nurse is caring for a client who sustained a basal skull fracture. when performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's nostril. which of the following actions should the nurse take first? Take the client's temperature. Place a dressing under the client's nose. Notify the charge nurse. Test the drainage for glucose.

-Test the drainage for glucose The greatest risk to a client who has a basal skull fracture is injury from cerebral spinal fluid (CSF) leak; therefore, the nurse should first test the drainage for glucose. Take the client's temperature. The nurse should take the client's temperature to ensure the client is afebrile to prevent infection and brain dysfunction; however, another finding is the priority. Place a dressing under the client's nose. The nurse should place a dressing under the client's nose to measure and collect the amount of drainage; however, another finding is the priority. Notify the charge nurse. The nurse should notify the charge nurse about the client's condition; however, another finding is the priority.

a nurse is collecting data from a client who has a possible cataract. which of the following manifestations should the nurse expect the client to report? 1 decrease color perception 2 loss of peripheral vision 3 bright flashes of light 4 eyestrain

1 decrease color perception Visual manifestations associated with cataracts can include decreased color perception and decreased visual acuity, even in daylight. Loss of peripheral vision Loss of peripheral vision occurs in clients who have open-angle glaucoma. Bright flashes of light Bright flashes of light and floaters are associated with retinal detachment. Eyestrain Eyestrain is associated with decreased visual acuity.

a nurse is caring for a client newly diagnosed with ovarian cancer. which of the following reactions from the client should the nurse initially expect? 1 denial 2 bargaining 3 acceptance 4 anger

1 denial

a nurse is evaluating discharge instructions for a client following a right cataract extraction. which of the following client statements indicates the teaching is effective? 1 i will take a stool softener until my eye is healed 2 i will expect to have moderately severe pain for 1-2 days 3 i will refrain from cooking for 1 week 4 i will bend at the waist to tie my shoes

1 i will take a stool softener until my eye is healed "I will take a stool softener until my eye is healed." The client should avoid straining during bowel movements to prevent an increase in intraocular pressure. "I will expect to have moderately severe pain for 1-2 days." The client should experience only mild pain post operatively. The client should report severe pain to the provider immediately. "I will refrain from cooking for 1 week." The client should avoid activities that can increase intraocular pressure, such as vacuuming; however, the client can perform activities, such as cooking, in moderation. "I will bend at the waist to tie my shoes." The client should bend at the knees, not the waist, to prevent an increase in intraocular pressure.

a nursing is caring for a client who has aphasia following a stroke. a family member asks the nurse how she should communicate with the client. which of the following is an appropriate response by the nurse? 1 incorporate nonverbal cues in the conversation 2 ask multiple choice question as part of the conversation 3 use a higher-pitched tone of voice when speaking 4 use simple child-like statements when speaking

1 incorporate nonverbal cues in the conversation The nurse should remind the family to use nonverbal cues to enhance the client's ability to comprehend and use language.

a nurse is reviewing HIPAA with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates a need for further instruction? 1 information about a client can be disclosed to family members at any time 2 HIPAA establishes regulations of health information in verbal, electronic, or written form. 3 a client's address would be an example of personally identifiable information 4 HIPAA is a federal law not a state law

1 information about a client can be disclosed to family members at any time

a nurse is collecting data from an adult client who has meningococcal meningitis. which of the following findings should the nurse expect? 1 petechial rash on the chest and extremities 2 tachycardia 3 negative kernig's sign 4 mild headache

1 petechial rash on the chest and extremities Petechial rash on the chest and extremities The nurse should expect to find a petechial rash over the chest and extremities of the client who has meningococcal meningitis. Tachycardia The nurse should expect to find bradycardia in the client who has meningococcal meningitis due to increased intracranial pressure. Negative Kernig's sign The nurse should expect the client who meningococcal meningitis to have a positive Kernig's sign due to meningeal irritation. Mild headache The nurse should expect the client who has meningococcal meningitis to exhibit a severe and persistent headache that is generally made worse by moving the client's head and neck.

a nurse is collecting data from a client who has a traumatic head injured. which of the following findings should the nurse report to the provider immediately? 1 sudden sleepiness 2 diplopia 3 headache 4 slight ataxia

1 sudden sleepiness Sudden sleepiness A client who has sudden sleepiness is unstable due to the increase in intracranial pressure. Therefore, the nurse should report this finding to the provider immediately. Diplopia The nurse should report the client's diplopia, which can indicates injury to the optic tract, to the provider. However, this is not the priority finding for nurse to report to the provider. Headache The nurse should report the client's headache, which is a response to the injury, to the provider. However, this is not the priority finding for the nurse to report to the provider. Slight ataxia The nurse should report the client's ataxia, which may be a symptom of cerebral injury, to the provider. However, this is not the priority finding for the nurse to report to the provider.

a nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. which of the following instructions should the nurse include in the teaching? 1 take the medication 45 minutes before eating 2 expect diaphoresis as a side effect of the neostigmine 3 if a medication dose is missed, wait until next scheduled dose to take the medication 4 treat nasal rhinitis with an over-the-counter antihistamine.

1 take the medication 45 minutes before eating Take the medication 45 minutes before eating. The nurse should instruct the client to take the medication before eating to allow the medication time to work and limit difficulty chewing and swallowing. Expect diaphoresis as a side effect of the neostigmine. The nurse should reinforce that diaphoresis is an indication of cholinergic crisis caused by overmedication with the neostigmine. It is a medical emergency. If a medication dose is missed, wait until the next scheduled dose to take the medication. The nurse should reinforce the importance of taking the medication on a strict schedule to minimize the potential for myasthenic crisis. This is manifested as increased muscle weakness, dysphagia, impaired speech, severe respiratory distress and anxiety. Treat nasal rhinitis with an over-the-counter antihistamine. The nurse should emphasize that the client should contact her provider before taking any over-the-counter medication. Antihistamines can actually worsen the symptoms of myasthenia gravis and should be avoided.

a nurse is collecting data from a client who has a score of 8 using the Glasgow coma scale. which of the following findings should the nurse expect? 1 the client requires total nursing care 2 the client is alert and oriented 3 the client is in a deep coma 4 the client has a stable neurological status

1 the client requires total nursing care The nurse should expect that a client who has a Glasgow Coma score of 8 is in a coma and requires total nursing care. The client is alert and oriented. The nurse should not expect a client who has a Glasgow Coma score of 8 to be alert and oriented. The client will be in a coma. The client is in a deep coma. The nurse should expect a client who is completely unresponsive and in a deep coma to have a Glasgow Coma score of 3. The client has a stable neurological status. The nurse should not expect a client who has a Glasgow Coma score of 8 to be stable neurologically. The client is in a coma.

a nurse is reinforcing teaching with a client who has glaucoma. which of the following statements should the nurse make? 1 without treatment, glaucoma can cause blindness 2 double vision is a common symptom of glaucoma 3 glaucoma results from the inadequate production of fluid within the eye 4 you will need to treatment glaucoma by instilling eye drops once a week

1 without treatment, glaucoma can cause blindness

a nurse is planning care for a client who has a cerebral aneurysm. which of the following actions should the nurse plan to take? 1. place the client in a darken room. 2 encourage self-care 3 administer a cleansing enema 4 administer an anticoagulant

1. place the client in a darken room. The nurse should place the client in a private, quiet, darkened room as part of the aneurysm precautions in order to prevent an increase in intracranial pressure. Encourage self-care. The nurse should not encourage the client to perform self-care, because this activity may elevate the client's blood pressure and increase intracranial pressure. Administer a cleansing enema. The nurse should not administer a cleansing enema, because straining or discomfort may elevate the client's blood pressure and increase intracranial pressure. Administer an anticoagulant. The nurse should not administer anticoagulants, which may cause a cerebral bleed from the aneurysm.

a nurse is caring for a client who has a seizure disorder and reports experiencing an aura. the nurse should recognize the client is experiencing which of the following conditions? 1 a continuous seizure state in which seizures occur in rapid succession 2 a sensory warning that a seizure is imminent 3 a period of sleepiness following the seizure during which arousal is difficult 4 a brief loss of consciousness accompanied by staring

2 a sensory warning that a seizure is imminent n aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and may involve any of the senses. The client can report "hearing bells", "seeing lights", or "smelling something". A continuous seizure state in which seizures occur in rapid succession Status epilepticus is a continuous seizure state in which seizures occur in rapid succession A period of sleepiness following the seizure during which arousal is difficult The postictal state is a period of sleepiness or lethargy following a seizure. A brief loss of consciousness accompanied by staring An absence, or petit mal, seizure is a brief loss of consciousness accompanied by staring.

a nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. which of the following actions should the nurse include in the plan? 1 position the client supine while in bed 2 change the nasal drip pad as needed 3 encourage frequent brushing of teeth 4 encourage the client to cough every 2 hr following surgery

2 change the nasal drip pad as needed The nurse should change the nasal drip pad as needed because the client will have nasal packing and bloody nasal drainage until the surgical site is healed Position the client supine while in bed. The nurse should place the client in a semi-Fowler's position to decrease intracranial pressure, which could lead to a cerebrospinal fluid leak. Encourage frequent brushing of teeth. The nurse should inform the client not to brush his teeth, because it will interfere with the healing process. Encourage the client to cough every 2 hr following surgery. The nurse should instruct the client to not cough, because it may interfere with the healing process and may lead to cerebrospinal fluid leak.

a nurse is modifying the diet of a client who has parkinson's disease and a prescription for selegiline, a monamine oxidase inhibitor (MAOI). which of the following foods should the nurse eliminate from the client's diet? 1 fresh fish 2 cheddar cheese 3 cherries 4 chicken

2 cheddar cheese The nurse should eliminate aged cheeses, such as cheddar cheese, from the diet of a client who has a prescription for selegiline because it contains tyramine, which can cause a hypertensive crisis. Fresh fish The nurse does not need to eliminate fresh fish from the diet of a client who has a prescription for selegiline. Cured meats containing tyramine should be eliminated from the client's diet. Cherries The nurse does not need to eliminate cherries from the diet of a client who has a prescription for selegiline. Foods containing tyramine should be eliminated from the client's diet. Chicken The nurse does not need to eliminate chicken from the diet of a client who has a prescription for selegiline. Foods containing tyramine should be eliminated from the client's diet.

a nurse is contributing to plan of care for a client who has increased intracranial pressure following a closed-head injury. which of the following interventions should the nurse recommend? 1 have the client perform huff coughing hourly 2 elevate the head of the bed 3 place pillows under the client's knees 4 encourage liberal fluid intake

2 elevate the head of the bed Elevate the head of the bed. ​The nurse should position the client in a neutral position with the head of the bed elevated to promote venous drainage from the brain and minimize pressure within the central nervous system.

a nurse is contributing to the plan of care for a client who has a terminal illness. which of the following interventions should the nurse identify as the priority? 1 promote the client's expression of feeling about loss of self-care ability 2 encourage the client to recall positive life events 3 schedule pain medication on a routine basis 4 suggest ways the client can continue interacting with social contacts

2 encourage the client to recall positive life events

a nurse collecting data from a client who has meniere's disease? which of the following is an expected finding for this client? 1 bilateral ear pain 2 gradual hearing loss 3 impacted cerumen 4 retracted eardrum

2 gradual hearing loss Bilateral ear pain Bilateral ear pain is an expected finding for a client who has otitis media. Gradual hearing loss An expected finding for a client who has Meniere's disease is tinnitus and gradual loss of hearing in one ear. Some clients also have hearing loss in both ears. Impacted cerumen Impacted cerumen is a common finding for older adult clients because, with aging, the wax becomes harder and drier. It is not an expected finding for a client who has Meniere's disease. Retracted eardrum Retracted eardrum is an expected finding for a client who has otitis media.

a nurse is collecting data from a client who has a possible medical diagnosis of guillain-barre syndrome (gbs). which of the following questions should the nurse ask the client? 1 have you had an MMR immunization? 2 have you had a recent upper respiratory infection? 3 have you travelled overseas recently? 4 are you taking a multivitamin?

2 have you had a recent upper respiratory infection? "Have you had an MMR immunization?" The nurse should ask the client if he has received the meningococcal conjugate vaccination because this vaccine has been associated with GBS, not the measles, mumps, and rubella (MMR) immunization. "Have you had a recent upper respiratory infection?" The nurse should ask the client about any recent upper respiratory infections. Although the cause of GBS is unknown, it usually follows a respiratory or gastrointestinal infection. "Have you traveled overseas recently?" The nurse should understand that overseas travel is not associated with GBS. "Are you taking a multivitamin?" The nurse should understand that taking a multivitamin is not associated with GBS.

a nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. the nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1 decreased pedal pulses 2 hypertension 3 peripheral edema 4 diarrhea

2 hypertension Decreased pedal pulses Decreased pedal pulses are a manifestation of impaired circulation. Hypertension Hypertension is an early manifestation of increased intracranial pressure. Other manifestations include restlessness, headache, and change in level of consciousness. The nurse should monitor and report manifestations of increased intracranial pressure. Peripheral edema Peripheral edema is a manifestation of fluid overload. Diarrhea Diarrhea is an adverse effect of many antibacterial medications, but not a manifestation of increased intracranial pressure.

a nurse is assisting with teaching a group of clients about monitoring for diabetic peripheral neuropathy. which of the following client statements indicates understanding of the information 1 i might notice a loss of feeling starting in my thighs and progressing down toward my feet 2 i might lose awareness of when I'm stepping on a harmful object 3 i can develop areas of red warmth on my feet 4 i can reverse manifestations of neuropathy by better controlling my blood sugar

2 i might lose awareness of when I'm stepping on a harmful object Peripheral neuropathy causes a loss of sensation in the feet, including general feeling and sense of position. The nurse should caution the group that this increases the risk of injury to the feet and for falls.

a nurse is providing discharge instructions for a client following outpatient cataract surgery with insertion of an intraocular lens. which of the following should the nurse include? 1 eye drops can cause halos to appear around lights 2 lying on the unaffected side can prevent complications 3 surgery can cause temporary reduced visual acuity 4 warm compresses over the surgical eye can reduce pain

2 lying on the unaffected side can prevent complications

a nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. which of the following interventions should the nurse take 1 insert a padded tongue blade into the client's mouth 2 place a pillow under the client's head 3 gently restrain the client's extremities 4 keep the client in a supine position

2 place a pillow under the client's head Insert a padded tongue blade into the client's mouth. The nurse should avoid placing anything in the client's mouth during a seizure due to the risk for injury and airway occlusion. Place a pillow under the client's head. The nurse should place a pillow or any soft padding under the client's head to protect the client from injury during the seizure. Gently restrain the client's extremities. The nurse should avoid restraining the client's extremities during a seizure due to the risk for injury. Keep the client in a supine position. The nurse should turn the client on his side or turn the head to the side to prevent aspiration of secretions.

a nurse is assisting with the plan of care for a client who has an intracranial aneurysm. which of the following interventions should the nurse include? 1 measure blood pressure, pulse, and respiration ever 4 hr 2 place the client in a private room 3 encourage the client to use an incentive spirometer 4 show the client how to move himself up in bed

2 place the client in a private room A client with a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety. The client should remain in a dark, private room. Measure blood pressure, pulse, and respiration ever 4 hr. The nurse should measure the client's blood pressure, pulse, and respirations at least every hour. ​Encourage the client to use an incentive spirometer. The client should not use an incentive spirometer, because it could increase intracranial pressure. Show the client how to move himself up in bed. The client should not move himself up in bed, because it could increase intracranial pressure.

a nurse is reviewing discharge instruction with the family of a client who sustained a minor head injury earlier in the day. which of the following instructions should the nurse include? 1. encourage the client to sleep for the first 24 hr 2 repeatedly ask the client questions to check for orientation 3 do not let the client engage in strenuous activities for 1 week 4 apply heat to the area of swelling for the first 48 hr

2 repeatedly ask the client questions to check for orientation The nurse should instruct the family to ask the client a variety of questions including where he is, who he is, and what happened to check for orientation.

a nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open-angle glaucoma. which of the following statements by the client indicates an understanding of the teaching? 1 when my vision improves, I will be able to stop taking the eye drops 2if I forget to take my eye drops, I should wait until the next time they are due 3 I should call the clinic before taking any over the counter medication 4 every two years I will need to have my vision checked by an eye doctor.

3 I should call the clinic before taking any over the counter medication Taking over-the-counter (OTC) medications that dilate the pupil could cause the client who has chronic open-angle glaucoma to experience an increase in intraocular pressure. A client who has glaucoma should always check with the provider before using OTC medications.

a nurse is collecting data from a client who has meningitis. when passively flexing the client's neck, the nurse notes an involuntary flexion of both legs. which of the following conditions is the client displaying? 1 kernig's sign 2 Nuchal rigidity 3 brudzinski's sign 4 bradykinesia

3 brudzinski's sign (manifesting Brudzinski sign, flexes hips & knees when the neck is flexed, a common sign of meningitis) The client is manifesting a positive Brudzinski's sign. This is manifested by the hips and knees flexing when neck is flexed, which is a common sign of meningitis. Kernig's sign ​The client who displays the Kernig's sign is unable to extend the leg completely when the thigh is flexed on the abdomen. Nuchal rigidity The client who displays nuchal rigidity has a stiff, painful neck when the head is flexed. Bradykinesia The client who displays bradykinesia has slow or no movement of extremities, which is a manifestation of Parkinson's disease.

a nurse at a community health clinic is caring for a client who reports a headache and stiff neck. which of the following actions should the nurse perform first? 1 obtain a throat culture specimen 2 perform a complete blood count 3 check the client's temperature 4 administer an oral analgesic

3 check the client's temperature The first action the nurse should take using the nursing process is to collect data from the client and check the client's temperature to determine if the client has a fever, as this is a manifestation of meningitis. Obtain a throat culture specimen. The nurse should obtain a throat culture specimen from clients reporting manifestations of meningitis; however, this is not the first action that the nurse should take. Perform a complete blood count. The nurse should obtain a venous sample for a complete blood count from clients reporting manifestation of meningitis; however, this is not the first action that the nurse should take. Administer an oral analgesic. The nurse should administer prescribed analgesics for clients reporting manifestations of meningitis; however, this is not the first action that the nurse should take.

a nurse is assisting with the plan of care for a client has a cerebral aneurysm. the nurse should plan to monitor the client for which of the following early indications of increased intracranial pressure? 1 projectile vomiting 2 decorticate posturing 3 disorientation to time and place 4 widening pulse pressure and bradycardia

3 disorientation to time and place Disorientation to time and place is an early indication of increased intracranial pressure. This finding occurs due to reduced oxygen and glucose in the brain.

a nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction from the left eye with the placement of an intraocular lens implant. which of the following statements by the client indicates a need for further teaching? 1 my eye may feel a little itchy for a while after surgery, but that's normal 2 i may have white drainage around my eye but its's not necessary to notify my surgeon about it 3 i will change my eye patch dressing every other day 4 my vision might be better by tomorrow

3 i will change my eye patch dressing every other day

a nurse is caring for a client who has hemiplegia following a stroke. the client's adult son is distressed over his mother's crying and condition. which of the following responses should the nurse make? 1 if you just sit quietly with your mother, im sure she will calm down 2 ill talk with your mother and see if i can comfort her 3 it must be hard to see your mother so ill and upset 4 your mother's crying seems to bother you more than it does her

3 it must be hard to see your mother so ill and upset "If you just sit quietly with your mother, I'm sure she will calm down." This response is non-therapeutic because it ignores the feelings of the son and provides false reassurance. "I'll talk with your mother and see if I can comfort her." This response is nontherapeutic because it is closed-ended and ignores the son's feelings of distress. "It must be hard to see your mother so ill and upset." This response is therapeutic because it demonstrates empathy and acknowledges the son's feelings of helplessness and powerlessness. "Your mother's crying seems to bother you more than it does her." This response is nontherapeutic because it belittles or rejects the son's feelings.

a home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. which of the following information should the nurse include in the plan of care?

"Rest in semi-Fowler's position."

A nurse is preparing a client for magnetic resonance imaging (MRI). Which of the following statements should the nurse include when reinforcing teaching? "You'll have to remove metal objects such as watches and body jewelry." "Your exposure to radiation will be minimal." "You will not be able to talk to the technician during the procedure." "Unlike an x-ray, the MRI allows you to move around a bit."

"You'll have to remove metal objects such as watches and body jewelry." The magnetic field of the scanner attracts metal objects such as jewelry and snaps or decorations on clothing. The field does not, however, attract materials made of steel or titanium.

a nurse is caring for a client who has increased intracranial pressure. which of the nursing interventions should the nurse take? Instruct the client to perform controlled coughing and deep breathing. Provide a brightly lit environment. Elevate the head of the bed 30°. Encourage a minimum intake of 2,000 mL/day of clear fluids.

-Elevate the head of the bed 30°. The nurse should elevate the head of the bed 15° to 30° to reduce intracranial pressure. Instruct the client to perform controlled coughing and deep breathing. The nurse should instruct the client to avoid coughing, which increases intracranial pressure. Provide a brightly lit environment. The nurse should provide the client with a nonstimulating environment to limit the risk of seizure activity. Encourage a minimum intake of 2,000 mL/day of clear fluids. The nurse should place the client on a fluid restriction to avoid increasing intracranial pressure.

a nurse is collecting data from a client who has an acoustic neuroma. which of the following manifestations should the nurse expect? 1 tinnitus 2 dysphagia 3 diplopia 4 apraxia

1 tinnitus

a nurse is assisting with the care of a client who has hypocalcemia. for which of the following signs should the nurse monitor? 1 brudzinski's sign 2 chvostek's sign 3 cullen's sign 4 kernig's sign

2 chvostek's sign

a nurse is caring for a client who has a spinal cord injury. the nurse suspects that the client has autonomic dysreflexia. which of the following actions should the nurse take first? 1. check the client for a fecal impaction 2 ensure the room temperature is warm 3 check the client's bladder for distention 4 raise the head of the bed

3 check the client's bladder for distention

a nurse at an outpatient surgery center is reinforcing discharge teaching with a client`s partner following surgical removal of a cataract. which of the following information should the nurse include in the teaching? 1 feed the client soft foods for several days 2 position the client on the affected side to rest 3 the client should remain in bed for 3 days 4 the client should wear dark glasses while outdoors

4 the client should wear dark glasses while outdoors

a nurse is contributing to the plan of a client who has diabetes insipidus. which of the following interventions should the nurse include?

Administer desmopressin.

A nurse is assisting with the plan of care for a client who is postoperative following repair of a detached retina. Which of the following interventions should the nurse include in the plan of care?

Apply an eye shield during naps and at bedtime.

a nurse is preparing to reinforce teaching with a client who has a new diagnosis of type 2 diabetes mellitus. which of the following actions is the nurse's priority in contributing to this plan?

Determine what the client knows about managing her diabetes.

A nurse notes that the left eyelid of a client who is unconscious remains partially open. To protect the eye, which of the following actions should the nurse take? Irrigate the eye daily with 0.9% sodium chloride irrigation solution. Dim the lights in the room. Instill ophthalmic ointment into the lower lid. Keep the client off her left side.

Instill ophthalmic ointment into the lower lid. To help prevent drying, the nurse should use artificial tears or ophthalmic ointment to keep the eye moist.

A nurse is collecting data as part of a neurological examination of a client who is receiving treatment for head trauma. Which of the following observations will give the nurse information about the function of the third cranial nerve? Instruct the client to look up and down without moving his head. Observe the client's ability to smile and frown. Evaluate the client's pupillary reaction to light. Ask the client to shrug his shoulders against passive resistance.

Instruct the client to look up and down without moving his head. The nurse should observe the client's extraocular eye movements as part of an evaluation of the function of the third cranial nerve.

A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI? Observe for the ability of the client to turn their head side to side. Have the client identify specific smells. Whisper in one of the client's ears while occluding the other. Check the client's visual acuity using a Snellen chart.

Observe for the ability of the client to turn their head side to side. The nurse should observe for the ability of the client to turn their head side to side when checking cranial nerve XI, the accessory nerve. The accessory nerve controls the muscles of the neck.

a nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. which of the following interventions should the nurse recommend?

Provide routine analgesia to minimize episodes of breakthrough pain

A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus? Serum sodium 145 mEq/L Urine specific gravity 1.028 Urine output 650 mL/hr Blood glucose 198 mg/dL

Urine output 650 mL/hr Diabetes insipidus is an endocrine disorder of the anterior pituitary gland. A decrease in antidiuretic hormone results in an increasingly high output of very dilute urine.

A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make? "I'm really not sure why the assistant is talking to him. Perhaps you should ask her." "Although your partner is not responding to us, he might still be able to hear." "Don't let that concern you. She talks to all her clients, no matter what." "She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner."

"Although your partner is not responding to us, he might still be able to hear." Hearing is one of the last senses to fade in clients who are unconscious. The nurse should encourage the partner and the staff to talk to him about neutral topics like the weather and benign current events to provide minimally stressful sensory stimulation.

a nurse is caring for a client following a complete spinal cord transection injury. the client's family asks the nurse what the term paraplegia means. which of the following responses should the nurse make? "He is unable move his lower body and legs." "He cannot move anything from the neck down." "His lower body and legs are extremely weak." "He has temporarily lost motor and sensory functions below the waist."

"He is unable to move his lower body and legs" "He is unable move his lower body and legs." Paraplegia is the loss of function (paralysis) of the lower trunk and limbs. A client who has a lumbar fracture and complete spinal cord transection has paraplegia.

A nurse is assisting with the admission of an older adult who is confused. Which of the following statements by the client's partner indicates that the client may be experiencing delirium? "Her behavior changed so quickly, I wasn't sure what was happening." "She became very withdrawn and extremely sad." "Her speech was slow and repetitious." "She's been making up stories the past few weeks."

"Her behavior changed so quickly, I wasn't sure what was happening." Delirium is an acute organic mental disorder characterized by an abrupt onset over hours to days.

a nurse is reinforcing teaching with a client who is scheduled for a ct scan of the head with contrast. which of the following statements by the client should the nurse identify as understanding of the teaching? 1 i can take medication up to 2 hr before the procedure 2 i will expect the procedure to last about 15 minutes 3 i will not eat or drink 4 hr after the procedure 4 i will feel a coolness or chills when the dye is injected

"I can take medication up to 2 hr before the procedure." ​Unless a particular medication is contraindicated or withheld by the provider, the client can take medications up to 2 hr prior to the test.

A nurse is reinforcing teaching with a client who has a new prescription for phenytoin. The nurse should recognize that which of the following statements by the client indicates a need for further teaching? "I will notify my provider before taking any other medications." "I have made an appointment to see my dentist next week." "I will take this medication with meals." "I'll be glad when my seizures stop so I can quit taking this medicine."

"I'll be glad when my seizures stop so I can quit taking this medicine." The client should not discontinue the phenytoin abruptly, because withdrawal from treatment can cause seizures to resume. Clients taking anticonvulsant medications often require them for life, and phenytoin should not be stopped unless indicated by the provider.

A nurse is caring for a client who has right-sided paralysis secondary to a stroke. The client's adult son states to the nurse, "None of this would have happened if I would've been there." Which of the following responses should the nurse make? "It seems that you feel responsible for what happened to your mother." "Your mother will be fine. I wouldn't worry so much." "Let's talk about how your mother's therapy sessions are going." "Why do you feel responsible for your mother's illness?"

"It seems that you feel responsible for what happened to your mother." This response demonstrates the therapeutic communication technique of reflecting. It directs feelings back to the son in a way that shows interest and caring and encourages further communication.

A nurse is caring for an older adult client who had a stroke. His partner tells the nurse that she is worried that he will never get better. Which of the following responses should the nurse make? "We have begun plans to send your husband to a rehabilitation facility as soon as he is stable." "Why are you so worried. I'm sure he will be just fine." "Don't worry. Most clients like your husband start making progress after a few days of rest." "You seem worried about your partner. Tell me how I can help."

"We have begun plans to send your husband to a rehabilitation facility as soon as he is stable." This response illustrates the nontherapeutic communication technique of invalidating the client's feelings and changing the subject, which can leave the client feeling isolated and hopeless.

a nurse is reinforcing discharge instruction with a client who has multiple sclerosis (MS) . which of the following instructions should the nurse include? "Wait to perform difficult tasks until later in the day." "Plan to relax in a hot tub spa each day." "Limit your intake of dairy products." "Implement a schedule to include periods of rest."

-"Implement a schedule to induce periods of rest." The nurse should instruct the client to implement a schedule with periods of exercise followed by periods of rest to maintain muscle strength and coordination. "Wait to perform difficult tasks until later in the day." The nurse should instruct the client to perform difficult tasks early in the day because fatigue worsens in the afternoon. "Plan to relax in a hot tub spa each day." The nurse should instruct the client to avoid extreme temperature changes, which may exacerbate the symptoms of MS. "Limit your intake of dairy products." The nurse should instruct the client to consume dairy products as well as foods containing calcium and vitamin D to help prevent osteoporosis, which can develop as a result of IV steroid treatments.

a nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. the nurse should monitor the client for which of the following manifestations of increased intracranial pressure? Polyuria Battle's sign Nuchal rigidity Lethargy

-Lethargy An early manifestation of increased intracranial pressure is lethargy. The nurse should monitor and report any changes in the client's level of consciousness, such as restlessness or disorientation, because these are early manifestations of increased intracranial pressure. Polyuria Polyuria is a manifestation of diabetes insipidus. Battle's sign Battle sign, or bruising behind the ear, is a manifestation of a skull fracture. Nuchal rigidity Nuchal rigidity, or neck stiffness, is a manifestation of meningitis or bleeding into the subarachnoid space.

a nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. which of the following interventions should the nurse include in the plan? Control impulsive behavior. Compensate for left visual field deficits. Re-establish communication. Improve left-side motor function.

-Re-establish communication. Control impulsive behavior. A client who has a right-hemisphere lesion is likely to be impulsive. Clients who have a left-hemisphere lesion are typically cautious. Compensate for left visual field deficits. A client who has a right-hemisphere lesion is likely to experience visual field deficits of the right side. Re-establish communication. A stroke is an interruption of the blood supply to a part of the brain, resulting in oxygen-deprived brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-hemispheric stroke, the nurse can anticipate that the client will have some degree of aphasia and will require communication-focused nursing interventions and speech therapy to re-establish communication. Improve left-side motor function. A client who has a right-hemisphere lesion can experience hemiplegia on the left side.

a nurse is reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. which of the following client statements should indicate to the nurse an understanding of the instructions? 1 ill splint my incision with a pillow to cough 2 ill lie flat in bed to cough and deep breath 3 ill start to use the incentive spirometer when i can get out of bed 4 ill breathe deeply and cough every 4 hours

1 ill splint my incision with a pillow to cough

a nurse is caring for a client who has global aphasia. which of the following actions should the nurse take? 1 use the exact same words when repeating statements 2 ask the client to multi-task 3 assist with communication by correctly stating words the client mispronounces 4 focus on a single form of communication

1 use the exact same words when repeating statements Use the exact same words when repeating statements. The nurse should repeat a statement, if necessary, using the exact same words. The client may have only understood the first half of the sentence the first time and will need to have it repeated to understand the second half of the statement. Ask the client to multi-task. The nurse should not ask the client to multi-task. The nurse should provide simple, one-step directions. Assist with communication by correctly stating words the client mispronounces. The nurse should not correct a client's mispronunciation because this may cause the client to become frustrated and give up on communicating. Focus on a single form of communication. The nurse should avoid using a single form of communication. The nurse should include a variety of aids to assist with communication such as pad and pencil, magic slates, and picture boards.

a nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. which of the following responses should the nurse make? 1 why have you changed your mind about the surgery? 2 bypass surgery must be very frightening for you 3 your provider would not have scheduled the surgery unless you needed it 4 i will call your doctor and have him discuss your surgery with you

2 bypass surgery must be very frightening for you "Why have you changed your mind about the surgery?" This response is nontherapeutic because it is probing the client for an explanation, which can cause the client to become defensive. "Bypass surgery must be very frightening for you." This response is therapeutic because it shows empathy and focuses on the client's feelings in a nonthreatening way, and it encourages the client to express his feelings. "Your provider would not have scheduled the surgery unless you needed it." This response is nontherapeutic because it minimizes the client's feelings and can appear judgmental or disagreeing. "I will call your doctor and have him discuss your surgery with you." This response is nontherapeutic because it does not address the client's feelings by refusal to discuss the issue.

a nurse is reinforcing teaching with the family of a client who has primary dementia. which of the following manifestations of dementia should the nurse include in the teaching? 1 temporary, reversible loss of brain function 2 forgetfulness gradually progressing to disorientation 3 sleeping more during the day than nighttime 4 hyper vigilant behaviors

2 forgetfulness gradually progressing to disorientation Dementia usually appears first as forgetfulness. Loss of functioning progresses slowly from impaired language skills and difficulty with ordinary, daily activities to severe memory loss and complete disorientation with withdrawal from social interaction. Temporary, reversible loss of brain function Dementia is a progressive, irreversible, decline that affects thinking and motor skills. Sleeping more during the day than nighttime Clients who have dementia wake frequently during the night. The nurse should expect a client who has acute delirium to exhibit a reversed sleep cycle. Hyper vigilant behaviors The nurse should expect a client who has delirium to possibly exhibit hypervigilant behavior.

a nurse is caring for a client who is scheduled for a surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. which of the following statements by the client should indicate to the nurse that the medication has been effective? 1 my mouth is very dry 2 i feel very sleepy 3 i am not hungry any longer 4 my leg feels numb

2 i feel very sleepy

a nurse is caring for a client who is scheduled for a tensilon challenge test to check for myasthenia gravis. which of the following findings should the nurse identify as a positive result? 1 a pill-rolling tremor appears. 2 muscle strength becomes temporarily stronger 3 electrical charge in the muscle increase in intensity 4 muscle strength shows no change

2 muscle strength becomes temporarily stronger About 1 min following injection of the medication, the nurse should expect the client to demonstrate improved muscle tone, which lasts only for about 5 min. This indicates a positive response to confirm diagnosis of myasthenia gravis.

a nurse is caring for a client who is unconscious and has lost the corneal reflex. which of the following actions should the nurse take? 1 keep the client's room darkened 2 place a patch over the eye 3 apply a warm saline compress to the eye 4 cleanse the eye with a mild soap

2 place a patch over the eye

a nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. which of the following findings should the nurse immediately report to the charge nurse? 1 edematous bruise on forehead 2 small drops of clear fluid in left ear 3 client disoriented to place 4 heart rate 110/min and regular

2 small drops of clear fluid in left ear ​Small drops of clear fluid from the ear are likely cerebrospinal fluid (CSF), which indicates that this client is at greatest risk for meningitis. Following a basilar skull fracture, a tear in the meninges can allow CSF to escape. Fluid might be noted in the ear canals or from the nose. The nurse should report this finding immediately.

a nurse is collecting data from a client who has a leaking cerebral aneurysm. which of the following findings should the nurse expect? 1 inability to speak for 30 min 2 sudden, severe headache 3 loss of bowel and bladder control 4 inability to move left or right extremities

2 sudden, severe headache A sudden, severe headache is a manifestation of a cerebral aneurysm. Other indications are neck stiffness and blurred vision.

a nurse is collecting data from a client who has a suspected cataract. the nurse should collect data from which of the following areas to confirm the diagnosis? 1 the posterior pharynx of the client's throat 2 the lens of the client's eye 3 the client's eyelid 4 the client's tongue

2 the lens of the client's eye

a nurse is reinforcing teaching with the family of a client who is in a halo fixation device. which of the following statements should the nurse make? 1 this device is used to treat injury to the lumbar spine 2 the purpose of this device is to immobilize the cervical spine 3 this device provides pain relief through compression of the spinal nerves 4 the purpose of this device is to allow the neck movement during the healing process

2 the purpose of this device is to immobilize the cervical spine

A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take? 1 obtain the number of the client`s provider 2 find a location for the client to sit. 3 call emergency medical services 4 drive the client to the nearest emergency room

3 call emergency medical services Call emergency medical services. The nurse should call emergency medical services immediately. The client is exhibiting manifestations of a stroke and requires immediate medical attention. Prompt medical intervention can reduce the risk of brain damage due to ischemia.

a nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that has client demonstrate decorticate posturing. which of the following findings should the nurse expect to observe? 1 extension of the extremities 2 pronation of the hands 3 plantar flexion of the legs 4 external rotation of the lower extremities

3 plantar flexion of the legs Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts. Extension of the extremities Extension of the extremities is an indicator of decerebrate rather than decorticate posturing. Pronation of the hands Pronation of the hands is an indicator of decerebrate rather than decorticate posturing. External rotation of the lower extremities Internal rather than external rotation of the lower extremities is an indicator of decorticate posturing.

a nurse is caring for the client who has meniere's disease. when asked by the client if he is allowed to ambulate independently. which of the following responses should the nurse make? 1 you are free to move around your room as you wish, but you should avoid the hallways 2 you are on strict bed rest and must not be up 3 please call for assistance when you wish to get out of bed 4 why would we not allow you to walk if you wanted?

3 please call for assistance when you wish to get out of bed

a nurse is caring for a client who if difficult to arouse and very sleepy for several hours following a generalized tonic seizure. which of the following descriptions should the nurse use when documenting this finding in the medical record? 1 aura phase 2 presence of automatisms 3 postictal phase 4 presence of absence seizures

3 postictal phase Aura phase The nurse should use the term "aura" to describe manifestations the client experienced prior to a seizure. Presence of automatisms The nurse should use the term "automatisms" to describe repetitive, non-purposeful actions a client might exhibit as part of a complex, partial seizure. Postictal phase The postictal phase is the recovery period following a tonic-clonic seizure. The client might be confused or agitated after a seizure and might sleep for several hours. Presence of absence seizures The nurse should use the term "absence seizure" to describe a brief loss of consciousness experienced by a client accompanied by staring.

a nurse is caring for a client who is unconscious following a stroke. which of the following nursing interventions is of highest priority? 1 perform passive range of motion on each extremity 2 monitor the client's electrolyte levels 3 suction saliva from the client's mouth 4 record the client's intake and output

3 suction saliva from the client's mouth Perform passive range of motion on each extremity. The nurse should perform passive range of motion for the client who is unconscious to help prevent complications of impaired physical mobility; however, another action is the priority. Monitor the client's electrolyte levels. The nurse should monitor the electrolyte levels for the client who is unconscious to help identify complications of altered nutritional status; however, another action is the priority. Suction saliva from the client's mouth. The greatest risk to the unconscious client is inability to independently maintain a clear airway. The client is at risk for ineffective airway clearance; therefore, the priority nursing action is to maintain the client's airway. Record the client's intake and output. The nurse should record the intake and output for the client who is unconscious to help identify complications of altered neurological status; however, another action is the priority.

a nurse is collecting data from a client who has type 1 diabetes mellitus. which of the following should the nurse expect? 1 blurred vision 2 pruritus 3 weight loss 4 drowsiness

3 weight loss

a nurse caring for a client who is recovering from a stroke. the client states "i feel like less of a man. my wife says she is thankful i am alive but i'm sure this is not how she expected us to spend our retirement years" which of the following is an appropriate response? 1 i agree with your wife, and you should be thankful that you are alive. 2 after an experience like this, everyone has feelings like these. 3 are you worried that you wife might leave you? 4 in what ways do you feel like you are less of a man?

4 "In what ways do you feel like you are less of a man?" The nurse should use the therapeutic technique of restating or rephrasing to encourage the client to state his concerns in greater detail.

a nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. the client becomes agitated and combative when the nurse approaches him. which of the following actions should the nurse plan to take? 1 turn the water on and ask the client to test temperature 2 obtain assistance to place mitten restraints on the client 3 firmly tell the client that good hygiene is important 4 calmly ask the client if he would like to listen to some music

4 calmly ask the client if he would like to listen to some music The nurse should remain calm to avoid agitating the client further. By offering to play music, the nurse may be able to distract the client and then reintroduce the idea of morning care. Turn the water on and ask the client to test the temperature. The nurse should recognize that hearing water running could increase the client's agitation, and asking the client to check the water temperature could cause injury to the client. Obtain assistance to place mitten restraints on the client. The nurse should not use restraints unless the client is at risk for harm to himself or others, and after attempting all other alternatives to restraints first. Firmly tell the client that good hygiene is important. The nurse should avoid using firm speech, which could be interpreted by the client as a threat and could increase his anxiety. The client has impaired cognition and thinking; therefore, reasoning intellectually with the client is not likely to be effective.

a nurse is contributing to the plan of care for a client following a lumbar puncture. which of the following interventions should the nurse include? 1 provide the client a low-sodium diet 2 change the client's dressing evert 12 hr 3 place the client in high-fowler's position 4 encourage oral fluids

4 encourage oral fluids ​A lumbar puncture is a diagnostic test of the cerebral spinal fluid. The provider will insert a needle into the subarachnoid space of the spinal canal and aspirate cerebral spinal fluid for diagnostic testing. In order to replace fluid the client loses during the test, the nurse should encourage oral fluid intake possibly up to 3,000 mL in 24 hr.

a nurse is contributing to the plan of care for a client who had a craniotomy. which of the following interventions should the nurse include in the plan? 1 place the client in a supine position 2 apply a warm cloth over the client's eyes 3 obtain a prescription for an opioid medication for pain 4 maintain seizure precautions

4 maintain seizure precautions Place the client in a supine position. The nurse should position the client on the nonoperative side to decrease venous collection and avoid any pressure on the surgical incision. Apply a warm cloth over the client's eyes. The nurse should place a cool cloth over the client's eyes. Obtain a prescription for an opioid medication for pain. The nurse should avoid the use of opioid medications for this client due to the potential for constipation, which can cause straining and an increase in intracranial pressure. Maintain seizure precautions. The nurse should monitor the client for seizures following a craniotomy and should maintain the client on seizure precautions.

a nurse is assisting the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. which of the following is an appropriate nursing action? 1 apply restraints 2 administer opioids 3 blacken the room 4 reduce stimuli

4 reduce stimuli The nurse should reduce stimuli by decreasing the number of visitors, remaining calm, and creating a quiet environment. ​Apply restraints. The nurse should avoid applying restrains which may increase the client's intracranial pressure. ​Administer opioids. The nurse should avoid administering opioids, which may suppress respiratory rate, constrict pupil reaction, and alter appropriate responsiveness. Blacken the room. The nurse should reduce the lighting in the client's room, not blacken the room, to decrease stimuli that may increase the client's intracranial pressure.

a nurse is planning care for several clients and is considering the clients' risk for stroke. which of the following conditions places the client at risk for an ischemic embolic stroke? A client who has uncontrolled hypertension A client who has chronic atrial fibrillation A client who has thrombocytopenia A client who has an arteriovenous malformation

A client who has chronic atrial fibrillation Chronic atrial fibrillation places a client at risk for embolic stroke because a small thrombus might dislodge and migrate to the brain.

A nurse in an assisted-living facility is caring for a client who is in early stages of dementia. The client has been oriented to name and place and is usually cooperative. Which of the following nursing actions is appropriate if the client refuses to take morning medications? Crush the pills, if not contraindicated, and hide them the client's in applesauce. Ask the client to express her reasons for refusing the morning medications and document the event. Try to talk the client into adherence by telling her the possible implications of missing a dose. Notify the charge nurse of the need for evaluation of the client's level of competence.

Ask the client to express her reasons for refusing the morning medications and document the event. Before intervening or making a judgment about the client's competence, the nurse should collect further data from the client. It is important to document the client's reasons in the client's own words, especially if the client is refusing prescribed medications or treatments.

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve XII? Observe for the ability of the client to turn their head side to side. Whisper in one of the client's ears while occluding the other. Have the client identify specific smells. Ask the client to stick out their tongue and observe if it is midline.

Ask the client to stick out their tongue and observe if it is midline. Cranial nerve XII is the hypoglossal nerve, which provides the motor function to the tongue. The nurse should check the hypoglossal nerve by asking the client to stick out their tongue and observe if it is midline. The nurse should also ask the client to move the tongue from side to side.

a nurse is caring for an older adult client who has colon cancer. the client asks the nurse several questions about his treatment plan. which of the following actions should the nurse take?

Help the client write down questions to ask his provider.

a nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. which of the following client behaviors should the nurse alert that the client is having difficulty adjusting to the loss of her breast?

Refusing to look at the dressing or surgical incision

a nurse is reinforcing preoperative teaching with a client who is scheduled for retinal detachment repair. which of the following instructions should the nurse include in the teaching?

Restrict head movements

a nurse is reinforcing discharge instructions for a client following a laminectomy. which of the following instructions should the nurse include?

Sit in straight-back chairs.

a nurse is collecting data from a client who has parkinson's disease and is experiencing bradykinesia. which of the following findings should the nurse expect? Increased blinking States of euphoria Slurred speech Decreased respiratory rate

Slurred speech The nurse should expect to observe slowed, slurred speech in a client who is experiencing bradykinesia. Increased blinking The nurse should expect to observe a decrease in blinking in a client who is experiencing bradykinesia. States of euphoria The nurse should expect to observe an expressionless, masklike face in a client who is experiencing bradykinesia. Decreased respiratory rate A decreased respiratory rate is not an expected finding in a client who is experiencing bradykinesia.

the nurse is collecting data from an older adult female client who has chronic hypothyroidism. which of the following findings should the nurse report to the provider immediately? 1 decrease level of consciousness 2 muscle cramps 3 report of hair loss 4 hoarse speech

decrease level of consciousness