Neurosensory and Musculoskeletal ATI, ATI - Neurosensory

What is it called when the brain attempts to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure

Cushing's response

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include?

Ensure the client lies flat for 4 to 8 hr.

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions?

"I should call my doctor if I experience a decrease in my vision."

A nurse is providing teaching a new prescription for cabidopa-levodopa for a client who has Parkinson's disease. Which of the following client statements indicates an understanding of the teaching?

"I should expect my urine to be a darker color."

A nurse is caring for a client who was admitted for status epilepticus and is on seizure precautions. Which of the following actions should the nurse plan to take?

Establish IV access.

A nurse is reinforcing teaching with a group of clients about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching?

A TIA can precede an ischemic stroke

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching?

"The drugs used to treat Alzheimer's disease can help delay cognitive changes."

A nurse is reinforcing teaching with a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching?

Avoid sudden movements

Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? (Select all that apply) a. The ability to select medications for the neurologic dysfunction Understanding of the tests used to diagnose neurologic disorders c. Knowledge of nursing interventions related to assessment and diagnostic testing d. Knowledge of the anatomy of the nervous system e. The ability to interpret the results of diagnostic tests

B, C, D

a reflex action of the toes; in adults is indicative of abnormalities in the motor control pathways leading from the cerebral cortex

Babinski reflex (sign)

A nurse is caring for a client who has a full arm cast and reports pain of 8 on a scale from 0 to 10 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

Check the circulation of the affected extremity.

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply.)

Crepititus with joint movement Decreased range of motion of the affected joint. Joint pain that resolves with rest.

A nurse is caring for a client in balanced suspension who reports intermittent muscle spasms. Which of the following actions should the nurse take first?

Check the position of the weights and ropes.

A nurse is collecting data from a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?

Cheyne-Strokes

abnormal movement marked by alternating contraction and relaxation of a muscle occurring in rapid succession

Clonus

A nurse is reinforcing teaching with a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?

Darken the lights

A nurse in a rehabilitation center is collecting data from a client who is recovering from a left hemisphere stroke. Which of the following findings should the nurse expect?

Difficulty with speech

A nurse is reinforcing teaching with a client who has a new diagnosis of primary open angle glaucoma (POAG). Which of the following information should the nurse include in the teaching?

Driving can be dangerous due to the loss of peripheral vision. Laser surgery can help reestablish the flow of aqueous humor.

The nurse is assessing a client in the post-ictal phase of a generalized tonic-clonic seizure. The nurse should determine if the client has which symptom following the seizure?

Drowsiness

A nurse is collecting data from a client who has a brain tumor. Which of the following findings indicates cranial nerve involvement?

Dysphagia

A nurse is reinforcing teaching with a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

Feeling of fullness in the ear

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?

I & Os

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

Intention tremors.

A nurse is assessing a client's extraocular eye movements as part of evaluating neurological functioning. This documents the status of which cranial nerves? (Select all that apply) Optic (II) Oculomotor (III) Trochlear (IV) Trigeminal (V) Abducens (VI)

Oculomotor (III) Trochlear (IV) Abducens (VI)

A nurse is caring for a client who has a closed head injury. The nurse should place the client in which of the following positions?

Semi-Fowler's

A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions would the nurse include? (select all that apply) a. Monitor the body for any skin rash b. Maintain adequate amounts of fluid and fiber in the diet c. Perform good oral hygiene, including daily brushing and flossing d. Receive necessary periodic blood work e. Report any problems with walking or coordination, slurred speech, or nausea

a,c,d,e

loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile

agnosia

Unresponsiveness to the environment; the patient makes no movement or sound but sometimes opens the eyes

akinetic mutism

An irreversible loss of all functions of the entire brain, including the brainstem

brain dead

A state in which the patient demonstrates awareness but cannot communicate thoughts or feelings

minimally conscious state

episode in which the patient experiences multiple seizures with no recovery time in between

status epilepticus

Cerebral arteries are more prone to rupture during hypertension because

thin and delicate

A nurse is developing a plan of care for a client for this patient who is scheduled for a cerebral angiogram with contrast dye. Which of the following statements by the client's family member should the nurse report to the provider? (Select all that apply) "She is allergic to shrimp." "I think she might be pregnant." "She takes Coumadin." "She is allergic to latex." "She takes antihypertensive medication."

"She is allergic to shrimp." "I think she might be pregnant." "She takes Coumadin."

A nurse is providing teaching to the partner of an older adult client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective?

"This medication should help my husband's daily function."

Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? (Select all that apply) Understanding of the tests used to diagnose neurologic disorders Knowledge of the anatomy of the nervous system Knowledge of nursing interventions related to assessment and diagnostic testing The ability to select mediations for the neurologic dysfunction The ability to interpret the results of diagnostic tests

*Understanding of the tests used to diagnose neurologic disorders *Knowledge of the anatomy of the nervous system *Knowledge of nursing interventions related to assessment and diagnostic testing

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

Monitor capillary refill at least every 4 hr.

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

Administer an oral dose of gabapentin to the client.

A nurse is reinforcing teaching about auras with a client who has a new diagnosis of simple partial seizures. Which of the following statements by the client indicates an understanding of the teaching?

An aura is a sensory warning that a seizure is imminent

A nurse in the emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurse's priority?

Assist with the Tensilon test.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions?

Remind the client to look consciously at both sides of his meal tray.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following findings should the nurse report to the provider?

Clear drainage from the nose.

A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect?

Constricted pupils

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)?

Cough

A nurse is reinforcing teaching with the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority?

Dysphagia

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level C5. The client report a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/ 110 mm Hg. Which of the following actions should the nurse take first?

Elevate the head of the client's bed.

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. The nurse should recognize which of the following findings is consistent with this diagnosis?

Elevated protein

What is priority on a patient when a persons LOC is declined and they cant follow commands and need stimuli to stay awake?

Maintain airway

A nurse working in the emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images indicates a comminuted fracture?

First image: http://imgur.com/GssMWM7

A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse report?

Flashes of bright light.

A nurse is reinforcing teaching with a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the teaching?

I will avoid bending over

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

Monitor pulse oximetry findings.

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include?

Move head slowly to decrease vertigo.

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside?

Oral nasal suction equipment

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface?

Pia matter

A nurse is collecting data from a client who has a high thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia?

Report of a headache

A nurse is caring for a client who is 8 hr postoperative following a craniotomy. Which of the following actions should the nurse take?

Report wound drainage greater than 50ml/ 8 hr.

A nurse is assessing a client who has a possible head injury following a motor vehicle crash. The nurse should recognize that which of the following findings indicates increasing intercranial pressure?

Restlessness.

test for cerebellar dysfunction that can be done with the patient seated or standing; inability to maintain position for 20 seconds is a positive test

Romberg's Test

A nurse is collecting data from a client who has a new diagnosis of acute angle closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?

Severe eye pain

A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the client's medication teaching plan?

Take medications at consistent time each day to maintain therapeutic blood levels.

A nurse reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure?

The client has a pacemaker

Which of the following ICP monitoring systems would the health care provider place that is most accurate and reliable, and allows for drainage of CSF

Intraventricular catheters

When the nurse performs oral hygiene for an unconscious client, which nursing intervention is the priority?

Keep suctioning near by

The nurse is caring for a client admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure?

LOC

A nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. Which of the following data is the priority for the nurse to collect to detect a change in the client's neurologic status?

Level of consciousness

A nurse is reinforcing teaching with the family of a client who has stage 2 Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching?

Limit choices offered to the client

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?

Maintain a PaCO2 of approximately 35 mm Hg.

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer?

Osmotic diuretics via IV bolus.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

Impulsive behavior.

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy?

Infection

A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

Instill a diluted alcohol solution into the ear after swimming.

A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery?

Intraocular hemorrhage

A client sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The client began having seizures and was given a sedative-hypnotic medication that is ultra-short acting and can be titrated to client response. What medication will the nurse be monitoring during this time?

Propofol

A nurse is reinforcing discharge teaching with the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure?

Protect the client's head

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer?

Recombiant tissue plasminogen activator.

A nurse is providing teaching for a client who is prescribed alendronate for osteoporosis. Which of the following information should the nurse include in the teaching?

Remain upright for 30 min after taking this medication.

A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. Which of the following indicates the position the nurse should teach the client to take when sitting?

Sitting upright with feet flat on floor.

A nurse is collecting data from a client who has a recent head trauma and a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to monitor for DI?

Specific gravity

A nurse is caring for a client who has spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?

Stroke the client's inner thigh.

A nurse is collecting data from a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?

Swelling behind the affected ear.

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?

The client rigidly extends his arms

A nurse is collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates to the nurse that the medication is having a therapeutic effect?

The client's urine output is 250 mL/hr

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect?

Ulnar deviation.

A nurse if reinforcing teaching with the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS?

Weakness of the distal extremities

A nurse is collecting data from a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect?

Weakness of the lower extremities

A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

Widened pulse pressure

A nurse is reinforcing discharge teaching with a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching?

You should expect to see flashing lights in front of the affected eye after the procedure

The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which foods/fluids for breakfast?

a full breakfast as desired without coffee, tea, or energy drinks

A condition resulting from a lesion in the pons in which the patient lacks all distal motor activity (paralysis) but cognition is intact

locked in syndrome

A 21-year-old female client takes clonazepam. What should the nurse ask this client about? (Select all that apply)

pregnancy status seizure activity alcohol