Neurosensory Disorders - ML8

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to insert an indwelling urinary catheter. increase the frequency of the catheterizations. place the client on fluid restrictions. use a condom catheter instead of an invasive one.

increase the frequency of the catheterizations. As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.

The nurse is assessing a client's motor response after brain surgery. The nurse pinches the client's skin to elicit a response and observes the client's arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response? extension posturing flaccid paralysis chronic spastic paralysis flexion posturing

extension posturing The client is exhibiting extension posturing indicating severe brain stem or midbrain damage which may be a sign of irreversible damage. Flaccid paralysis occurs when there is no resistance to passive range of motion or voluntary movement. Flexion posturing, is a sign of brain damage and communication with nerves in the spinal cord and not as dangerous a sign as extension posturing. Chronic spastic paralysis results from damage to the voluntary movement system between the brain and the muscles.

Which nursing approach is most helpful to a client with Parkinson disease who is experiencing a freezing of gait with difficulty initiating movement? Have the client remain still. Tell the client to march in place. Instruct the client to use a wheelchair. Pull the client forward to initiate walking.

Tell the client to march in place. When a freezing gait occurs, having the client march in place or step over actual lines, imaginary lines, or objects on the floor can promote walking. Instructing the client to take one step backward and two steps forward may also stimulate walking. Pulling the client forward can cause imbalance. The nurse does not instruct the client to use a wheelchair. The client obtains much exercise as possible; having the client remain still does not help the client obtain the momentum needed to walk.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? decreased norepinephrine level increased acetylcholine level decreased acetylcholine level increased norepinephrine level

decreased acetylcholine level A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.

The client with a lumbar laminectomy asks to be turned onto the side. The nurse should: get another nurse to help logroll the client into position. turn the client's shoulders first, followed by the hips and legs. inform the client that because of the laminectomy, it is possible to only lie supine. ask the client to help by using an overhead trapeze to turn.

get another nurse to help logroll the client into position. After a laminectomy, the client's spine must be maintained in proper alignment. The client may be turned to the side by logrolling in one unit while keeping the back straight. It takes at least two people to perform this procedure correctly.Reaching up and using the trapeze will put stress on the operative area and cause the spinal column to twist. Such motions interfere with healing and can cause pain.Turning the shoulders then the hips will cause the spine to rotate, which is contraindicated in the immediate postoperative period.Clients who have had a laminectomy should be assisted to side-lying positions to take pressure off the sacral area and stimulate circulation; however, position changes must be done so that the back stays in straight or neutral alignment.

A nursing goal immediately following surgery for a client who has had a cataract removed is: the client describes methods to prevent an increase in intraocular pressure. the client states headaches have disappeared. the client has clear vision. the client understands how to administer pain medication.

the client describes methods to prevent an increase in intraocular pressure. Preventing an increase in intraocular pressure is the primary concern after cataract removal.Vision will remain unclear temporarily after surgery.Cataracts do not cause headaches.Pain medication at home is not required.

The nurse observes that the client with multiple sclerosis looks untidy and sad. The client suddenly says, "I can't even find the strength to comb my hair," and bursts into tears. Which response by the nurse is best? "It must be frustrating not to be able to care for yourself." "Tell me more about how you're feeling." "How many days have you been unable to comb your hair?" "Why hasn't your husband been helping you?"

"Tell me more about how you're feeling." By asking the client to tell more about how she is feeling, the nurse is not making any assumptions about what is troubling the client. The nurse should acknowledge the client's feelings and encourage her to discuss them. Saying that this situation must be frustrating involves assumptions by the nurse about why the client is crying and is not a therapeutic response. Asking how long the client has been unable to comb her hair takes the focus off her feelings and inhibits therapeutic communication. Inquiring why the client's husband has not helped insinuates that the husband is not helping enough, which is inappropriate, takes the focus off the client's feelings, and inhibits therapeutic communication.

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse meets with the team to develop a change strategy based on indicators. Which statement by a team member shows a need for further teaching regarding performance management? "We can discipline the ED staff for not getting the clients to the ICU fast enough." "We can collaborate with staff from the ED and the ICU to formulate strategies and implement change." "We can review ED staffing to see if shortages affect ICU admission." "We can use statistics gathered in the ED during triage to determine the average time for admission to the ICU."

"We can discipline the ED staff for not getting the clients to the ICU fast enough." Using statistics and other indicators, such as ED staffing information, to develop a change strategy is part of performance management. Disciplining staff doesn't reflect a strategy based on indicators. Collaborating with staff from other areas results in performance improvement, not performance management.

A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" Which response by the nurse is most appropriate? "You sound upset. Please share with me what you're feeling." "I have cared for several clients who have gotten over their frustrations with ALS. With time you can, too." "I understand why you're frustrated, but with a positive attitude you will get better." "This feeling is normal. The staff are here and want to help you in any way possible."

"You sound upset. Please share with me what you're feeling." Addressing the client's feelings of frustration and using an open-ended statement is the best therapeutic response by the nurse. Stating the client will get better is inaccurate information; ALS is a chronic, progressive, degenerative neurological disease that is incurable and invariably fatal. A therapeutic answer focuses on the client. Stating staff are here to help and addressing past clients with ALS removes the focuses from the client.

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. What should the nurse tell the client to do to prepare for this test? "You will need to hold your head very still during the examination." "You must shampoo your hair tonight to remove all oil and dirt." "You may drink fluids until midnight, but after that drink nothing until the scan is completed." "You will have some hair shaved to attach the small electrode to your scalp."

"You will need to hold your head very still during the examination." The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea. There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved.

A registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel are caring for a group of clients. The RN asks the assistive personnel to check the pulse oximetry level of a client who underwent a laminectomy. The assistive personnel reports that the pulse oximetry reading is 89% on room air. The client has a prescription for oxygen at 2 L/min for a pulse oximetry level below 92%. The RN is currently assessing a postoperative client who just returned from the postanesthesia care unit. How will the RN proceed? Complete the assessment of the new client before attending to the client who underwent laminectomy. Ask the assistive personnel to notify the provider of the low pulse oximetry level. Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the provider. Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Because it's important to get more information about the client with a decreased pulse oximetry level, the RN should ask the LPN to obtain vital signs and administer oxygen as prescribed. The RN must attend to the newly admitted client without delaying treatment to the client who is already in their care. The RN can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The RN doesn't need to immediately attend to the client with a decreased pulse oximetry level; the RN may wait until the newly admitted client's assessment is complete. The primary health care provider doesn't need to be notified at this time because the client has a prescription for oxygen administration.

A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer? Administer the medications quickly and ask the nursing assistant and LPN to finish providing care for the clients. Tell the ICU they have to wait to transfer the client because everyone is too busy to accept the client. Notify the supervisor that the client care assignment is unsafe with the addition of the new client, and insist the supervisor assist with the assignment. Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU.

Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU. The registered nurse should use the ancillary staff to help effectively manage the group of clients. While the registered nurse accepts the client from the ICU, the nursing assistant can provide care for the clients, and the LPN can administer the remaining medications. Telling the ICU to wait or notifying the supervisor that they must assist are incorrect options because the nurse should assess the situation and use the ancillary staff appropriately. The nurse has adequate staff to safely provide care for this group of clients. The nurse shouldn't administer medications quickly because haste is an unsafe practice that could lead to a medication error. Instead of rushing, the nurse should delegate the responsibility to the LPN.

A client with amyotrophic lateral sclerosis (ALS) is admitted with weight loss and malnutrition. The client can swallow without difficulty. While caring for the client, the nurse discovers that the weight loss is related to the client's refusal to eat. The client states to the nurse that they would rather die than remain alive with this disease. How should the nurse intervene? Support the client's decision because they have a fatal disease. Report this finding to the client's family, and suggest they talk with the physician about having a feeding tube placed. Ask the physician to consult a psychiatrist because the client is exhibiting suicidal behavior. Explore the client's feelings about dealing with ALS using open-ended questions.

Explore the client's feelings about dealing with ALS using open-ended questions. The nurse shouldn't just support the client's decision. Instead, using open-ended questions, the nurse should explore the client's feelings about living with ALS. After obtaining more information, the nurse should notify the physician of the client's wishes. The nurse shouldn't discuss the client with family members without the client's permission; doing so is a breach of client confidentiality. After evaluating the client, the physician can determine whether a psychiatric consult is necessary.

A short time after cataract surgery, the client has nausea. What should the nurse do first? Medicate the client with an antiemetic, as prescribed. Explain that this is a common feeling that will pass quickly. Instruct the client to take a few deep breaths until the nausea subsides. Tell the client to call the nurse promptly if vomiting occurs.

Medicate the client with an antiemetic, as prescribed. A prescribed antiemetic should be administered as soon as the client has nausea following a cataract extraction. Vomiting can increase intraocular pressure, which should be avoided after eye surgery because it can cause complications. Deep breathing is unlikely to relieve nausea. Postoperative nausea may be common; however, it does not necessarily pass quickly and can lead to vomiting. Telling the client to call only if vomiting occurs ignores the client's need for comfort and intervention to prevent complications.

After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior? The client has developed tolerance to the dose of morphine. Other coping mechanisms are exhausted. The morphine dosage is too high. The client is addicted to the morphine.

The client has developed tolerance to the dose of morphine. Tolerance to a regular opioid dose can develop with frequent use. The client experiences increased discomfort, asks for medication more frequently, and exhibits anxious and restless behavior. Such actions are often misinterpreted as indicative of dependence or addiction.Addiction is a psychological condition in which a client takes drugs for nontherapeutic reasons; this client is receiving morphine for pain control. The client's symptoms do not suggest that the dosage is too high. No data are given about the client's coping mechanisms.

Sodium polystyrene sulfonate is prescribed for a client following a crush injury. Which finding indicates the drug has been effective? The ECG is showing tall, peaked T waves. The pulse is weak and irregular. There is muscle weakness on physical examination. The serum potassium is 4.0 mEq/L (4.0 mmol/L).

The serum potassium is 4.0 mEq/L (4.0 mmol/L). Following a crush injury, serum potassium rises to high levels. Sodium polystyrene sulfonate is a potassium-binding resin. The resin combines with potassium in the colon and is then eliminated, and serum potassium levels should come back to normal. Normal serum potassium is 3.5 to 5.3, so a level in this range indicates that the medication has been effective. A weak, irregular pulse and tall peaked T waves on ECG are signs of hyperkalemia, and muscle weakness is a sign of hypokalemia.

Which client should receive the pictured examination first? a client with chest tightness and heartburn a client with nausea, vomiting, and abdominal pain a client with facial drooping and left-sided weakness a client with fatigue, fever, and productive cough

a client with facial drooping and left-sided weakness The nurse in this examination is assessing the pupils and neurological function. A detailed neurological assessment is a priority for a client with clinical manifestations of a stroke, including facial drooping and left-sided weakness. A client with fatigue, fever, and productive cough most likely has a respiratory infection. Nausea and vomiting indicate abdominal issues. A client with chest tightness and heartburn may be having cardiac ischemia. While a neurological assessment is important for all these clients, the priority is the client with signs and symptoms of a neurological issue.

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will: actively participate in the rehabilitation process as appropriate. exhibit no further episodes of short-term memory loss. be able to return to his construction job in 3 weeks. be emotionally stable and display pre-injury personality traits.

actively participate in the rehabilitation process as appropriate. Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? suctioning the client once each shift encouraging oral fluid intake administering a stool softener as ordered elevating the head of the bed 90 degrees

administering a stool softener as ordered To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

A client has had a cerebrovascular accident, which has affected the left side of the client's brain. The nurse should assess the client for which symptom? aphasia apraxia agnosia dyslexia

aphasia Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia. Dyslexia, the inability of a person with normal vision to interpret written language, is thought to be due to a central nervous system defect in the ability to organize graphic symbols. Apraxia is the inability to perform purposeful movements in the absence or loss of motor power, sensation, or coordination. Agnosia is the loss of comprehension of auditory, visual, or other sensations despite an intact sensory sphere.

A client who has been treated for chronic open-angle glaucoma for 5 years asks the nurse, "How does glaucoma damage my eyesight?" What should the nurse tell the client? "Your glaucoma: is caused by decreased blood flow to the retina." results from chronic eye inflammation." leads to detachment of the retina." causes increased intraocular pressure."

causes increased intraocular pressure." In COAG, there is an obstruction to the outflow of aqueous humor, leading to increased intraocular pressure. The increased intraocular pressure eventually causes destruction of the retina's nerve fibers. This nerve destruction causes painless vision loss. The exact cause of glaucoma is unknown. Glaucoma does not lead to retinal detachment.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck their head on the pier railing. According to friends, "The client was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, the client began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? involuntary posturing irregular breathing pattern declining level of consciousness (LOC) pupillary asymmetry

declining level of consciousness (LOC) With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage? flat with the head turned to the right head of the bed elevated to 30 degrees side-lying on left side head elevated on two pillows

head of the bed elevated to 30 degrees The head of the bed should be elevated 30 degrees to promote venous drainage and decrease intracranial pressure. The client's head should be in a midline, or neutral, position. Clients with supratentorial surgery should be positioned on the nonoperative side to prevent displacement of the cranial contents by gravity.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? evaluation of pain and discomfort lung auscultation and measurement of vital capacity and tidal volume evaluation of nutritional status and metabolic state evaluation for signs and symptoms of increased intracranial pressure (ICP)

lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. The client reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? migraine headache Bell's palsy angina pectoris trigeminal neuralgia

trigeminal neuralgia Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris.

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term? dystrophic helicopod ataxic steppage

helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes rise high off the floor and the heel comes down heavily with each step.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? Provide sensory stimulation. Position the client with the head turned toward the side of the brain tumor. Encourage coughing and deep breathing. Administer stool softeners.

Administer stool softeners. Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

The nurse is educating a client and family about macular degeneration. Which photo would be utilized to best illustrate what these clients typically see?

Macular degeneration is a medical condition that typically affects the eyesight of older adults. The central vision is most affected in clients, thus revealing a blurred or distorted image in the middle of the visual field. Peripheral vision is usually maintained. The visual field is neither totally blurred, unless in an advanced case, nor completely clear.

Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin? Notify the health care provider (HCP) if vision changes occur. Store gabapentin in the refrigerator. Take gabapentin with an antacid to protect against ulcers. Take all the medication until it is gone.

Notify the health care provider (HCP) if vision changes occur. Gabapentin may impair vision. Changes in vision, concentration, or coordination should be reported to the HCP. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Monitor the client's heart rhythm. Obtain a urine specimen for drug screening. Prepare for gastric lavage.

Prepare to assist with ventilation. Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

Which goal is a priority for a client who has undergone surgery for retinal detachment? Prevent an increase in intraocular pressure. Maintain a darkened environment. Cleanse the eye with soap and water. Control pain.

Prevent an increase in intraocular pressure. After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal. Control of pain with analgesics is a secondary goal. The client should avoid getting soap and water in the eye when bathing. Maintaining a darkened environment is not necessary for this client.

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first? Test the nasal drainage for glucose. Look for a halo sign after the drainage dries. Contact the physician. Have the client blow their nose.

Test the nasal drainage for glucose. Because cerebrospinal fluid (CSF) contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. The nurse should look for a halo sign only if the drainage is blood tinged. A client with a suspected CSF leakage shouldn't blow their nose; doing so could increase the risk of injury. The nurse should contact the physician after completing the assessment.

An older adult has hearing loss and a sensation of fullness in both ears. The nurse should examine the ears for: accumulation of cerumen in the internal canal. accumulation of cerumen in the external canal. inflammation of the external canal. presence of a bony growth in the ear.

accumulation of cerumen in the external canal. Cerumen (ear wax) commonly gets impacted in older clients in the external canal. Otalgia is the "fullness" sensation or pain that an older client may experience when the cerumen becomes impacted.External otitis is an inflammation of the outer ear and would not explain the symptoms the client is experiencing.A bony growth (exostosis) arises from the surface of a bone and would not explain the symptoms the client is experiencing.

When developing the home care plan for a client with glaucoma, the nurse should encourage the client to: minimize exercise. add extra lighting to his home. wear dark glasses using cell phones, computers, or tablets. reduce daily fluid intake.

add extra lighting to his home. Miotic agents may compromise a client's ability to adjust safely to night vision. For safety, extra lighting should be added to the home.The client does not need to curtail fluid intake.It is not necessary to wear dark glasses when using computers, tables, or cell phones.Exercise is permitted, although excessive exertion should be avoided.

An elderly client has suffered a cerebrovascular accident (CVA). The right side of the client's face has visible ptosis. The nurse would be alert to which finding? agenesis xerostomia epistaxis dysphagia

dysphagia Dysphagia is difficulty swallowing. The same nerve that controls the drooping of the face can cause dysphagia. The other choices are not associated with CVA. Agenesis is absence or incomplete development of an organ or body part. Epistaxis is a nose bleed. Xerostomia is a dry mouth.

The son of an older adult reports that his father just "stares off into space" more and more in the last several months but then eagerly smiles and nods once the son can get his attention. What further assessments should the nurse make? dementia hearing loss anger depression

hearing loss Blank looks, decreased attention span, positioning of the head toward sound, and smiling/nodding in agreement once attention is gained are all behaviors that indicate hearing loss in adults. It is common to confuse sensory deficits for a change in cognitive status. The nurse should focus assessments of sensory function on considering any pathophysiology of existing or new-onset deficits and consider all client factors that might contribute to deficits.

Which is an early symptom of glaucoma? blurred or "sooty" vision hazy vision loss of central vision. impaired peripheral vision

impaired peripheral vision In glaucoma, peripheral vision is impaired long before central vision is impaired.Hazy, blurred, or distorted vision is consistent with a diagnosis of cataracts.Loss of central vision is consistent with senile macular degeneration, but it occurs late in glaucoma.Blurred or "sooty" vision is consistent with a diagnosis of detached retina.

A client with a ruptured intervertebral disc at L4-L5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. How should the nurse interpret this finding? The client has: motor changes. alteration of reflexes. postural deformity. sensory changes.

postural deformity. Standing with a flattened spine slightly tilted forward and slightly flexed to the affected side indicates a postural deformity. Motor changes would include findings such as hypotonia or muscle weakness. Absent or diminished reflexes related to the level of herniation would indicate alteration in reflexes. Sensory changes would include findings such as paresthesia and numbness related to the specific tract of the herniation.

Which goal is collaboratively established by the client with Parkinson's disease, the nurse, and the physical therapist? to build muscle strength to improve muscle endurance to reduce ataxia to maintain joint flexibility

to maintain joint flexibility The primary goal of physical therapy and nursing interventions is to maintain joint flexibility and muscle strength. Parkinson's disease involves a degeneration of dopamine-producing neurons; therefore, it would be an unrealistic goal to attempt to build muscles or increase endurance. The decrease in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor system effects. Attempts to reduce ataxia through physical therapy would not be effective.

The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the healthcare provider? worsening headache tachycardia diminished pedal pulses frequent coughing

worsening headache A worsening headache is a clinical manifestation associated with a vasospasm. The development of cerebral vasospasm is a serious complication of subarachnoid hemorrhage and is a leading cause of morbidity and mortality in those who survive the initial hemorrhage. Frequent coughing, tachycardia, and diminished pedal pulses are not as concerning as a worsening headache.

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? "Limit your fruit and vegetable intake." "Avoid hot baths and showers." "Avoid taking daytime naps." "Restrict fluid intake to 1,500 ml/day."

"Avoid hot baths and showers." The nurse should instruct a client with MS to avoid hot baths and showers because they may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.

The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply. Limit alcohol intake. Eat a high-protein diet, with at least two servings of lean meat per day. Limit fluid intake to no more than 1 L/day. Limit sodium intake to 1,500 mg/day. Eat a low-purine diet.

Eat a low-purine diet. Limit alcohol intake. Gout is characterized by an abnormal metabolism of uric acid. Individuals either produce too much uric acid or their body is unable to metabolize and excrete it. Purines are metabolized into uric acid. The client who suffers from gout would be placed on a low-purine diet with foods such as peanut butter, cherries, rice, pasta, fruits, and vegetables. Fluids and sodium do not have to be limited. Alcohol intake would be limited as it is thought to trigger an exacerbation.

The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? The tremors sometimes disappear with purposeful and voluntary movements. There is no explanation for the observation; it is a chance occurrence. The tremors are probably psychological and can be controlled at will. The tremors disappear when the client's attention is diverted by some activity.

The tremors sometimes disappear with purposeful and voluntary movements. Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for: bradycardia paralytic ileus sudden, severe hypertension hot, dry skin

sudden, severe hypertension With a cervical injury, the client has sympathetic fibers that can be stimulated to fire reflexively. The firing is cut off from brain control and is both reflexive and massive. It classically produces pounding headache and dangerously elevated blood pressure, "goose bumps," and profuse sweating.Bradycardia, paralytic ileus, and hot, dry skin typically occur during spinal shock, not during autonomic dysreflexia.

Which is an initial sign of Parkinson's disease? bradykinesia rigidity akinesia tremor

tremor The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? Turn out the lights in the room. Encourage the client to close their eyes. Alternatively patch one eye every 2 hours. Instill artificial tears.

Alternatively patch one eye every 2 hours. Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to do what? Divert attention from the source of pain. Decrease the perception of pain. Tolerate the pain. Escape the source of pain.

Escape the source of pain. The client's innate responses to pain are directed initially toward escaping from the source of pain. Variations in tolerance and perception of pain are apparent only in conscious clients, and only conscious clients can employ distraction to help relieve pain.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do? Explain how to overcome a freezing gait by telling the client to march in place. Assist the UAP with getting the client back in bed. Have the UAP keep a steady pull on the client to promote forward ambulation. Give the client a muscle relaxant.

Explain how to overcome a freezing gait by telling the client to march in place. Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.

A client is having a cataract removed and will use eyeglasses after the surgery. What information should the nurse include in the teaching plan? Select all that apply. The changes will be immediate. Images will appear one-third larger. Stay out of the sun for 2 weeks. Use handrails when climbing stairs. Look through the center of the glasses.

Images will appear one-third larger. Look through the center of the glasses. Use handrails when climbing stairs. The use of glasses following cataract surgery does not totally restore binocular vision. Glasses will cause images to appear larger, and peripheral vision will be distorted; the client should look through the center of the glasses and turn his or her head to view objects in the periphery. The client should also use caution when walking or climbing stairs until he or she has adjusted to the change in vision. Changes in vision following cataract surgery are not immediate, and the nurse can instruct the client to be patient while adjusting to the changes. The client does not need to stay out of the sun but should wear dark glasses to prevent discomfort from photophobia.

A nurse is assessing a client with meningitis. The nurse places the client in a supine position and flexes the client's leg at the hip and knee. The nurse notes resistance when straightening the knee and the client reports pain. The nurse should document what neurologic sign as positive? Kernig's sign Lichtheim's sign Brudzinski's sign Babinski's reflex

Kernig's sign A positive Kernig's sign is a manifestation of meningeal irritation. The nurse can elicit this sign by placing the client in a supine position and flexing the leg at the hip and knee. Pain or resistance when the knee is straightened suggests meningeal irritation. Babinski's reflex — dorsiflexion of the great toe with extension and fanning of the other toes — is an abnormal reflex elicited by firmly stroking the lateral aspect of the feet with a blunt object. Babinski's reflex is an indicator of corticospinal damage and may indicate meningitis but is not being assessed here. A positive Brudzinski's sign (flexion of the hips and knees in response to positive flexion of the neck) also signals meningeal irritation but is not being assessed in this scenario. Lichtheim's sign is the inability to speak associated with subcortical aphasia.

The nurse is administering eye drops to a client with glaucoma. Which technique is correct for instilling the eye drops? The eye drops are placed: on the scleral surface. near the opening of the lacrimal ducts. on the cornea. in the lower conjunctival sac.

in the lower conjunctival sac. Eyedrops are correctly instilled by placing them in the lower conjunctival sac. Eyedrops should not be placed near the lacrimal ducts, to decrease the chance of the medication's being systemically absorbed. Placing the drops on the cornea or sclera is uncomfortable for the client and may cause the medication to run out of the eye socket instead of being absorbed.

A client is receiving an I.V. infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? increased urine output elevated blood pressure decreased heart rate decreased level of consciousness (LOC)

increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

Which nursing action addresses the primary concern for a client with Guillain-Barré syndrome? monitoring for mental status changes placing the client on cardiac monitoring placing the client on isolation precautions preparing for mechanical ventilation

preparing for mechanical ventilation As this disease progresses, the nurse can expect the client to have weakness and possible paralysis of the diaphragm. This may lead to respiratory failure and require mechanical ventilation. This is the primary concern for the client. The other issues are not as high a priority as maintaining a patent airway.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? speaking in short sentences writing directions so client can read them using a "picture board" for the client to point to pictures speaking loudly

using a "picture board" for the client to point to pictures Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

The nurse is teaching a young female about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client makes which statement? "Since I'm 28 years old, I shouldn't delay starting a family." "I'll need a higher dose of oral contraceptive when on this drug." "I'll use one of the barrier methods of contraception." "I must weigh myself weekly to check for sudden gain in weight."

"I'll use one of the barrier methods of contraception." An alternative or additional method of birth control must be used because oxcarbazepine reduces the effectiveness of oral contraceptives. Higher doses of oral contraceptives will not help in achieving this purpose, but the client needs an additional or alternative method of birth control. The client does not need advice about when to start a family. A side effect of oxcarbazepine may be weight gain, but it is typically gradual.

The nurse teaches an adolescent about returning to school after a concussion. Which statement by the client reflects the need for more teaching? "I must slowly return to my previous activity level as my symptoms improve." "Time is the most important factor in my recovery." "My symptoms may reemerge with exertion." "I should limit my activities that require concentration."

"Time is the most important factor in my recovery." While recovery from a concussion takes time, adequate rest and limiting exertion facilitate recovery. Both physical and cognitive exertion can cause the reemergence of symptoms and delay recovery. As symptoms resolve, clients may slowly return to previous levels of activity.

The client with a cataract tells the nurse about being afraid of being awake during eye surgery. Which response by the nurse would be the most appropriate? "Have you ever had any reactions to local anesthetics in the past?" "There is really nothing to fear about being awake. You will be given a medication that will help you relax." "What is it that disturbs you about the idea of being awake?" "By using a local anesthetic, you will not have nausea and vomiting after the surgery."

"What is it that disturbs you about the idea of being awake?" The nurse should give a client who seems fearful of surgery an opportunity to express her feelings. Only after identifying the client's concerns can the nurse intervene appropriately. Asking the client about previous reactions to local anesthetics may be warranted, but it does not address the client's concerns in this instance. Telling the client that he or she will not have nausea or vomiting ignores the client's feelings of fear and does not provide any data about the client's feelings. More data would help the nurse plan care. Telling the client that there is nothing to be afraid of minimizes her feelings and does not address her concerns. Premature explanations and clichés do not provide the needed assessment data and ignore the client's feelings.

A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?

15 The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of eye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores the best on all three assessments scores 15 points.

The client reports that the nasal packing is uncomfortable and asks when it will be removed. The nurse should tell the client the nasal packing is usually removed: 24 to 48 hours after surgery. after nasal edema subsides. the day of surgery. after pain has diminished.

24 to 48 hours after surgery. The purpose of nasal packing is to prevent bleeding. Once hemostasis has been achieved, usually in 24 to 48 hours, the packing can be removed. Nasal edema may not completely resolve for a few weeks.The presence or absence of pain does not influence the timing for removal of nasal packing.

The client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out? Teach deep-breathing exercises. Administer morphine sulfate. Teach leg lifts and muscle-setting exercises. Administer atropine sulfate.

Administer atropine sulfate. Atropine sulfate causes pupil dilation. This action is contraindicated for the client with glaucoma because it increases intraocular pressure. The drug does not have this effect on intraocular pressure in people who do not have glaucoma. Morphine causes pupil constriction. Deep-breathing exercises will not affect glaucoma. The client should resume taking all medications for glaucoma immediately after surgery.

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first? Advise the client to keep the container closed tightly and protected from light. Advise the client to discard the drug because it may have undergone chemical changes or become contaminated. Advise the client to obtain a fresh container of pilocarpine solution to avoid omitting ordered doses. Watch the client or a family member administer the drug to determine possible contamination sources.

Advise the client to discard the drug because it may have undergone chemical changes or become contaminated. A cloudy solution indicates that the drug has changed chemically or has become contaminated. Therefore, the nurse first should advise the client to discard the drug. Advising the client to obtain a fresh container of pilocarpine, watching the client or a family member administer the drug, and advising the client to keep the container closed tightly and protected from light are all appropriate actions to take after telling the client to discard the solution.

Which measure would be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery? Apply ice compresses. Blow the nose gently. Lie in a prone position. Apply warm, moist compresses.

Apply ice compresses. The most effective way to decrease discomfort is to decrease local edema. Cold application, such as an ice compress or ice bag, is effective.Heat dilates local vessels and increases local congestion.Semi-Fowler's position helps decrease edema and prevents aspiration.Nose blowing should be avoided for at least 48 hours after the nasal packing is removed because it can disrupt the surgical site and lead to bleeding.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? Document the reading because it reflects that the treatment has been effective. Check the equipment. Contact the physician to review the care plan. Continue the assessment because no actions are indicated at this time.

Check the equipment. A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

A client who has Ménière's disease reports having frequent attacks of vertigo. The nurse should include which information in the client's teaching plan? Select all that apply. Increase the protein in the diet. Consider using a cane to maintain balance during an attack. Sit down if dizzy. Administer an opioid to relieve headache. Avoid bright lights if they make the symptoms worse.

Consider using a cane to maintain balance during an attack. Sit down if dizzy. Avoid bright lights if they make the symptoms worse. During an acute attack of vertigo, it is best for the client to sit or lie down in a quiet room, avoid sudden position changes, and avoid bright lights if they aggravate the symptoms. Safety is of utmost importance as clients can lose their balance during an attack of vertigo; using a cane can prevent falls. There is not conclusive evidence about the effects of diet, but a low-sodium diet may be helpful in decreasing the number of attacks; the client should also avoid caffeine. Headaches typically are not a component of the vertigo attack.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Face the client and establish eye contact. Switch topics frequently to keep the client's attention. Talk in a louder than normal voice. Talk slowly and enunciate each word.

Face the client and establish eye contact. When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. Enunciating each word is unnecessary. The nurse should allow the client at least 30 seconds to respond to questions or follow a command. Clients with aphasia may need more time to process and understand information. Nurses should use short, simple sentences and avoid frequently changing topics. It is unnecessary to speak in a louder or softer voice than normal.

A client is discharged to home following hospitalization for percutaneous endoscopic gastrostomy tube placement to assist with nutrition. The client's primary diagnosis is amyotrophic lateral sclerosis (ALS). The client can transfer from the bed to a chair but can't walk. The client and their family are concerned about the client's ability to maintain mobility at the highest possible level following a surgical procedure. The nursing diagnosis most appropriate for this client is Impaired memory related to reduced quality and quantity of information processed. Hopelessness related to impaired ability to cope. Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate. Caregiver role strain related to care recipient's unrealistic expectations of caregiver.

Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate. The family's focus should be on Impaired physical mobility. Although the client's spouse may be experiencing caregiver role strain, the client's unrealistic expectations may not be the cause of the strain. Impaired memory and Hopelessness don't apply to the concerns of this client and family.

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions? Eat foods containing vitamins C, D, and E, and drink at least 2 L of fluid a day. Eat foods and ingest fluids that will cause the urine to be less acidic. Drink a large amount of fluids, especially milk products, and eat a diet that includes multiple sources of vitamin D. Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.

Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. Increasing fluid intake will provide an internal irrigation and dilute the urine. This will lessen the probability of renal calculi forming. Cranberry juice is helpful in acidifying the urine and lessening the incidence of cystitis. Ingesting large amounts of milk and vitamin D will not decrease incidence of a UTI or renal calculi. Foods containing vitamins will not necessarily prevent these problems, nor will less acidic urine.

A client with chronic pain reports to the manager that the nurses have not been responding to requests for pain medication. What is the manager's priority action? Check the medication record and the nurses' notes for the last couple of days. Perform a pain assessment and pain history on the client. Meet with the nurses responsible for this client. Have the clinical nurse educator review an in-service on pain management.

Meet with the nurses responsible for this client. A manager must assess the performance of staff in relation to this client. After information is gathered from the nurses, information can also be obtained from the records and the client. The clinical educator can be of assistance if there is a knowledge deficit regarding pain management.

When assessing the client with Parkinson's disease, the nurse should observe the client for: an exaggerated sense of euphoria. dry mouth. a stiff, masklike facial expression. aphasia.

a stiff, masklike facial expression. Typical signs of Parkinson's disease include drooling; a low-pitched, monotonous voice; and a stiff, masklike facial expression.Dry mouth is not associated with Parkinson's disease.Aphasia is not a symptom of Parkinson's disease.An exaggerated sense of euphoria would not be typical; more likely, the client would exhibit depression, probably related to the progressive nature of the disease and the client's difficulties dealing with it.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? absence of reflexes along with flaccid extremities spasticity of all four extremities positive Babinski's reflex along with spastic extremities hyperreflexia along with spastic extremities

absence of reflexes along with flaccid extremities During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates cranial nerves I and II. cranial nerves III and V. cranial nerves IX and X. cranial nerves VI and VIII.

cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates dysfunction in the brain stem. dysfunction in the cerebrum. risk for increased intracranial pressure. dysfunction in the spinal column.

dysfunction in the brain stem. Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? turned onto the operative side elevated no more than 10 degrees elevated 30 degrees flat

elevated 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

Which nursing goal is realistic to establish with a client who has multiple sclerosis (MS)? improved muscle strength greater joint flexibility clearer thinking fewer mood swings

improved muscle strength MS is a progressive, chronic neurologic disease characterized by patchy demyelination throughout the central nervous system. This interferes with the transmission of electrical impulses from one nerve cell to the next. Care for the client with MS is directed toward maintaining muscle strength, preventing deformities, preventing and treating depression, and providing client motivation. MS affects speech, coordination, and vision, but not cognition.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? increased intracranial pressure (ICP) status epilepticus shock encephalitis

increased intracranial pressure (ICP) When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? infection high blood pressure coma apnea

infection The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP, not complications.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? weight loss polyuria tetanic contractions jugular vein distention

jugular vein distention Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? setting a regular time for elimination limiting fluid intake to 1,000 mL/day eating a diet high in fiber using an elevated toilet seat

limiting fluid intake to 1,000 mL/day Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position.

Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? facial grimaces, patting motions, and lip smacking jerking in one extremity that spreads gradually to adjacent areas loss of consciousness, body stiffening, and violent muscle contractions vacant staring and abruptly ceasing all activity

loss of consciousness, body stiffening, and violent muscle contractions A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.

Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia? assessing laboratory test results as ordered administering zolpidem tartrate monitoring the patency of an indwelling urinary catheter placing the client in the Trendelenburg's position

monitoring the patency of an indwelling urinary catheter A full bladder can precipitate autonomic dysreflexia. The nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position cannot prevent autonomic dysreflexia.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? occipital parietal temporal frontal

occipital The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.

The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which? positions the client on the back with a small pillow under the head cleans the client's mouth and teeth with a toothbrush opens the client's mouth with a padded tongue blade keeps portable suctioning equipment at the bedside

positions the client on the back with a small pillow under the head The UAP should position an unconscious client on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he or she aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.

Which goal is the most realistic for a client diagnosed with Parkinson's disease? to maintain optimal body function to cure the disease to stop progression of the disease to begin preparations for terminal care

to maintain optimal body function Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. However, many clients live for years with the disease: and it would not be appropriate to start planning terminal care at this time.

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment? to serve as a stopgap measure until help arrives to eliminate the need for medical care to prevent vision loss to hasten formation of scar tissue

to prevent vision loss Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim should always seek medical care. Eye irrigation isn't considered a stopgap measure.

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. The client's level of consciousness is decreased, and they require nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client? Take no special precautions for this client. Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. Use standard precautions, which require gloves for suctioning. Put on gloves, a mask, and eye protection.

Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis.

A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? "Depression may manifest as dementia in elderly clients." "The most common cause of dementia in the elderly is Alzheimer's disease." "Dementia is a terrible disease of the elderly." "Drug interactions are the most common cause of dementia in the elderly."

"The most common cause of dementia in the elderly is Alzheimer's disease." The nurse should inform the family member that Alzheimer's disease is the most common cause of dementia in elderly clients. Dementia is a clinical manifestation, not a disease process. Although drug interactions and overmedication are causes of dementia, these causes aren't as common as Alzheimer's disease. Depression is common in elderly clients, but it doesn't cause dementia.

A nurse is caring for a client who has returned to their room after a carotid endarterectomy. Which action should the nurse take first? Place antiembolism stockings on the client. Ask the client if they have a headache. Ask the client if they have trouble breathing. Take the client's blood pressure.

Ask the client if they have trouble breathing. The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.

A nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement? Administer the medication for complaints of muscle weakness or difficulty swallowing. Warn the client that they'll experience mouth dryness. Give the medication on an empty stomach. Give the medication before meals with a small amount of food.

Give the medication before meals with a small amount of food. Because neostigmine's onset of action is 45 to 75 minutes, it should be administered at least 45 minutes before eating to improve chewing and swallowing. Taking neostigmine with a small amount of food rather than on a completely empty stomach reduces GI adverse effects. Adverse effects of the medication include increased salivation, bradycardia, sweating, nausea, and abdominal cramps. Neostigmine must be given at scheduled times to ensure consistent blood levels.

For a neurologically injured client, the nurse should assess motor strength by: comparing equality of hand grasps. observing spontaneous movements. asking the client to signal when feeling pressure applied to the feet. observing the client feed himself or herself.

comparing equality of hand grasps. Comparing equality of hand grasps is a technique used to assess motor strength.The ability to move spontaneously demonstrates motor ability but not strength.Noting that the client can feed himself or herself verifies coordination and motor ability but does not help determine muscle strength.Having the client signal when pressure is applied to the feet tests sensory function.

Sensorineural hearing loss results from which condition? sclerosis of the bones of the middle ear presence of fluid and cerumen in the external canal response to a traumatic experience damage to the cochlear or vestibulocochlear nerve

damage to the cochlear or vestibulocochlear nerve A sensorineural hearing loss results from damage to the cochlear or vestibulocochlear nerve. Presence of fluid and cerumen in the external canal or sclerosis of the bones of the middle ear results in a conductive hearing loss. Hearing loss resulting from a traumatic experience is called a psychogenic hearing loss.

A client has chronic open-angle glaucoma. What should the nurse ask the client about when conducting a focused assessment? decreasing peripheral vision colored light flashes excessive lacrimation eye pain

decreasing peripheral vision Although COAG is usually asymptomatic in the early stages, peripheral vision gradually decreases as the disorder progresses. Eye pain is not a feature of COAG but is common in clients with angle-closure glaucoma. Excessive lacrimation is not a symptom of COAG; it may indicate a blocked tear duct. Flashes of light are a common symptom of retinal detachment.

Atropine sulfate is contraindicated as a preoperative medication for which client? A client with: diabetes. chronic obstructive pulmonary disease (COPD). pyelonephritis. glaucoma.

glaucoma. Atropine is contraindicated in clients with glaucoma because it increases intraocular pressure. It is not contraindicated in clients with diabetes, pyelonephritis, or COPD.

The nurse is planning dietary needs with a client who is in the early postoperative period after nasal surgery. The nurse should tell the client to: increase fluid intake. limit intake of high-fiber foods. take an antiemetic before eating. drink through a straw.

increase fluid intake. Although foods as tolerated are encouraged, the nurse should encourage the client with nasal packing to increase fluid intake because fluids are easier for the client at this time because nasal packing makes eating difficult and uncomfortable. The packing blocks the passage of air through the nose, creating a partial vacuum during swallowing. Using a straw will increase the vacuum. Antiemetics are needed only if the client experiences nausea or vomiting. There is no need to limit intake of high-fiber foods.

The best method to remove cerumen from a client's ear involves: using a cerumen curette. inserting a cotton-tipped applicator into the external canal. using aural suction. irrigating the ear gently.

irrigating the ear gently. Irrigation is the first strategy to loosen cerumen. Successful removal of the cerumen involves gentle irrigation behind the impacted cerumen. The flow of the solution must be behind the impaction to remove the cerumen from the canal.A cotton-tipped applicator or other device is not appropriate because it can cause damage to the eardrum.Use of aural suction or a cerumen curette is appropriate only if the impacted cerumen cannot be removed by irrigation.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate? meningeal irritation encephalitis increased intracranial pressure (ICP) low cerebrospinal fluid (CSF) pressure

meningeal irritation Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign and Kernig's sign don't indicate increased ICP, encephalitis, or low CSF pressure.

A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately? pain in the lower back when the leg is lifted pain in the lower back that radiates to the hip diffuse, aching sensation in the L4 to L5 area new onset of foot drop

new onset of foot drop Neurologic symptoms, such as foot drop, or bowel or bladder changes, should be reported to the HCP immediately. When musculoskeletal strain causes back pain, these symptoms may take 4 to 6 weeks to resolve. As an accompanying symptom of acute low back pain, the client may have a diffuse, aching sensation in the L4 to L5 area, pain in the lower back when the leg is lifted, or pain that radiates to the hip.

The primary goal in the plan of care for the client after cataract removal surgery is to: prevent fluid volume excess. maintain a darkened environment. promote safety at home. increase cardiac output.

promote safety at home. Promoting safety is a priority goal for this client. The client's vision will not be clear, and the client may need to wear an eye patch after surgery. Orienting the client to the physical environment, assisting the client during ambulation, and following other safety precautions to reduce the risk of injury are required. Cardiac output and fluid volume excess are unrelated to cataract surgery. Maintaining a darkened environment is neither necessary nor safe.

A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority? risk for injury activity intolerance impaired verbal communication impaired physical mobility

risk for injury Left homonymous hemianopsia causes loss of vision in half of the right visual field so clients cannot see past the midline without turning the head to that side, leaving the client at risk for injury. The client who has had a stroke may have impaired physical mobility, activity intolerance, and impaired verbal communication but these are not the priority according to Maslow's hierarchy of needs.

An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element? fluids sodium potassium protein

sodium Ménière's disease is commonly seen in older women; the disorder is caused by pressure within the labyrinth of the inner ear as a result of excess endolymph resulting in swelling in the cochlea. Therefore, the nurse should instruct the client about dietary restrictions of sodium to reduce fluid retention. Pharmacologic treatment includes antivertiginous drugs and diuretics. If the client is prescribed a diuretic, the fluid and electrolytes are monitored. The amount of protein does not have a direct influence in this disease process.

The nurse observes a visitor having a tonic-clonic seizure on the floor in the hallway of the acute care floor. What is the nurse's appropriate intervention when caring for the visitor? protecting the visitor's head with a pad to prevent injury placing an object between the teeth to prevent airway obstruction laying the visitor on the back restraining the visitor to prevent harm

protecting the visitor's head with a pad to prevent injury Protect the head with a pad to prevent injury from striking hard surfaces during the seizure. After the visitor begins to have a seizure, nothing should be attempted to be inserted into the mouth. Broken teeth and injury to the mucosa may result. The visitor should be placed on the side if at all possible to facilitate drainage of saliva and mucus.

Which statement indicates that a client understands the nurse's teaching about phenytoin for the diagnosis of seizures? "I will only be on this type of medication for a short while." "This medication can help reduce my anxiety." "This medication may keep me awake." "This medication will not cure my disease."

"This medication will not cure my disease." Phenytoin is an antiseizure medication and it will not cure seizures. Most clients are on antiseizure medications for a lifetime, and one of the side effects of phenytoin is drowsiness. Phenytoin does not reduce anxiety.

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? asking the client to speak louder when tired asking the client to repeat indistinguishable words encouraging the client to speak slowly encouraging the client to speak distinctly

asking the client to speak louder when tired Asking a client to speak louder even when tired may aggravate the problem. Asking the client to speak slowly and distinctly and to repeat hard-to-understand words helps the client to communicate effectively.

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? providing passive range of motion exercises to the left extremities during the bed bath putting high top tennis shoes on the client after bathing pulling up the client under the left shoulder when getting the client out of bed to a chair elevating the foot of the bed to reduce edema

pulling up the client under the left shoulder when getting the client out of bed to a chair Pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive range-of-motion exercises prevent contractures and atrophy. Raising the foot of the bed assists in venous return to reduce edema. High top tennis shoes are used to prevent foot drop.

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial? day care for the granddaughter regular exercise weekly visits by another person with MS psychotherapy

regular exercise An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients.

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? decreasing systolic blood pressure unequal pupil size tachycardia decreasing body temperature

unequal pupil size Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

A client who has Ménière's disease is experiencing an acute attack of vertigo. What should the nurse do to help the client manage the attack? Give the client cheese and crackers. Administer acetaminophen. Darken the client's room and provide a quiet environment. Offer carbonated fluids.

Darken the client's room and provide a quiet environment. During an acute attack of vertigo, it is best for the client to lie down in a darkened, quiet room and to avoid sudden position changes. Because vertigo is frequently accompanied by nausea and vomiting, the client will not want to eat or drink. Headaches are not a component of the vertigo attack. Fluids are usually administered parenterally to maintain hydration and administer medications.

A nurse is caring for a client with Alzheimer disease who was admitted to the hospital from a nursing home. The hospital staff is having difficulty managing the client's urinary incontinence because the client wanders around the unit all day. What is the most appropriate action by the nurse to assist with elimination? Ask the health care provider to prescribe sedation to allow the client to rest. Teach the client Kegel exercises to increase voluntary control over urination. Incorporate a toileting schedule into the pattern of the client's wandering. Have the client wear a pad and a brief to ensure the absorption of incontinent urine.

Incorporate a toileting schedule into the pattern of the client's wandering. Incorporating the client's toileting schedule into the wandering assists with elimination and increases the chance of continence. Sedation will decrease the client's mobility but does not address the frequent incontinent episodes. The stem indicates the client's incontinence is related to wandering, not a weakened pubococcygeus (PC) muscles. Therefore, teaching Kegel exercises is unnecessary. Additionally, clients with Alzheimer disease have difficulty with thought and memory; therefore, teaching can be challenging. A pad and brief at the same time does not ensure urine absorption nor do they address the incontinence issue.

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability? "I won't be able to have sexual intercourse until the urinary catheter is removed." "I can participate in sexual activity but might not experience orgasm." "I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay." "I should be able to participate in sexual activity, but I'll be infertile."

"I can participate in sexual activity but might not experience orgasm." The woman with spinal cord injury can participate in sexual activity but might not experience orgasm. Cessation in the nerve pathway may occur in spinal cord injury, but this does not negate the client's mental and emotional needs to creatively participate with her partner in a sexual relationship and to reach orgasm. An indwelling urinary catheter may be left in place during intercourse and need not be removed because the indwelling urinary catheter is placed in the urethra, which is not the channel used for sexual intercourse. There are no contraindications, such as hypertension, to sexual activity in a woman with spinal cord injury. Sexual intercourse is allowed, and hypertension should be manageable. Because a spinal cord injury does not affect fertility, the client should have access to family planning information so that an unplanned pregnancy can be avoided.

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The parent questions pain medication for home. Which response by the nurse is most appropriate? "Opioid medications may lead to vomiting, which increases the intracranial pressure (ICP)." "Maybe the health care provider will prescribe ibuprofen for the head pain." "Pain medication is avoided after a head injury to avoid hiding a worsening condition." "Your child has a mild concussion; acetaminophen can be given."

"Your child has a mild concussion; acetaminophen can be given." Following MRI of the brain, it is confirmed that there is no bleeding on the brain; thus, pain medication may be administered. The mother asks for medication for a headache. The most appropriate response is that acetaminophen may be given. Opioids may mask changes in the level of consciousness (LOC) that indicate increased intracranial pressure (ICP); therefore, it would not be given. Also, this level of analgesia is not typically given for mild concussions. Ibuprofen is a common over-the-counter pain reliever; however, ibuprofen is a nonsteroidal anti-inflammatory medication, which reduces the ability of the blood to clot.

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? Risk for deficient fluid volume related to vomiting Acute pain related to vertigo Imbalanced nutrition: Less than body requirements related to nausea and vomiting Risk for injury related to vertigo

Risk for injury related to vertigo Vertigo, the chief finding in Ménière's disease, is a severe, rotational whirling sensation that typically causes the client to fall when attempting to stand or walk. Because client safety is paramount, the nursing diagnosis of Risk for injury related to vertigo takes priority. Vertigo doesn't cause pain. Although nausea and vomiting may lead to inadequate nutrition and fluid loss, these problems are secondary to client safety.

A nurse has received a shift report on four clients. Which client should the nurse assess first? a middle-age adult who had a rhizotomy 2 days earlier a young adult admitted for observation and management of migraine headaches an older adult admitted 3 hours earlier for observation because of possible transient ischemic attack an older adult returning to the unit after having a carotid endarterectomy

an older adult returning to the unit after having a carotid endarterectomy The nurse should first assess the client returning from a carotid endarterectomy, who requires close monitoring. The client who had a rhizotomy will require pain assessment after the nurse addresses the client returning from surgery. The clients admitted for observation are stable and are lower priorities than the client returning from a carotid endarterectomy.

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition? widening pulse pressure decrease in the pulse rate decrease in level of consciousness (LOC) dilated, fixed pupils

decrease in level of consciousness (LOC) A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear? inner ear external ear middle ear tympanic membrane

inner ear A client with vertigo experiences problems with the inner ear, which is responsible for maintaining equilibrium. The external ear collects sound; the middle ear conducts sound. The tympanic membrane (eardrum) vibrates in response to sound stimulation.

The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease? high protein low fat low sodium low carbohydrate

low sodium A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière's disease.

A client recently experienced a stroke with accompanying left-sided paralysis. The family voices concerns about how to best interact with the client. They report the client doesn't seem aware of their presence when they approach the client on the left side. What advice should the nurse give the family? "The client is unaware of their left side. You need to encourage them to interact from this side." "The client is unaware of their left side. You should approach them on the right side." "The client is feeling an emotional loss. They'll eventually start acknowledging you on the left side." "This condition is temporary."

"The client is unaware of their left side. You should approach them on the right side." The client is experiencing unilateral neglect and is unaware of their left side. The nurse should advise the family to approach on the nonaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.

What is the priority nursing intervention in the postictal phase of a seizure? Determine the client's level of sleepiness. Reorient the client to time, person, and place. Assess the client's breathing pattern. Position the client comfortably.

Assess the client's breathing pattern. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

The nurse is instructing a client with Ménière's disease how to recognize vertigo. The nurse should tell the client to notice: an episode of blackout. a feeling that the environment is in motion. light-headedness. narrowed vision preceding fainting.

a feeling that the environment is in motion. Vertigo is a form of hallucination in which the person perceives the environment to be moving around him or her or perceives he or she is moving within the environment.Ménière's disease does not cause blackouts, fainting, or lightheadedness.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP)? Place the client in a jacket restraint. Wrap the hands in soft "mitten" restraints. Apply a wrist restraint to each arm. Tuck the arms and hands under the sheet.

Wrap the hands in soft "mitten" restraints. It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the sheet restrict movement and add to feelings of being confined, all of which would add to the agitation and increase ICP.

A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? hemiplegia, seizures, and decreased level of consciousness (LOC) difficulty breathing or swallowing nausea, vomiting, and profuse sweating tachycardia, tachypnea, and hypotension

hemiplegia, seizures, and decreased level of consciousness (LOC) Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure and monitors the blood pressure for signs of widening pulse pressure. The client's current blood pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole number.

90 Pulse pressure is the difference between the systolic blood pressure and the diastolic blood pressure. For this client, pulse pressure is 170 - 80 = 90.

A nurse is caring for a client with severe depression. The client reports changes in appetite and sleep pattern and loss of a job because of the effects of the depression. The client has two young children at home and states, "I just wish things could be like they were. I feel so helpless that I can't even get out of bed in the morning." The physician has ordered electroconvulsive therapy (ECT) for the client in addition to the client's current antidepressant medications. A nurse evaluates the ECT therapy as effective when the client is suddenly cheerful, is very social at the nurses' station, and wants to see all the family members. is discharged from the hospital. begins to have memory loss about the depression and seems happier. sleeps through the night, eats 80% of meals, and is out of bed.

sleeps through the night, eats 80% of meals, and is out of bed Return to normal sleeping patterns and eating habits shows improvement in depressive symptoms. Memory loss is an adverse effect of ECT but doesn't demonstrate symptom improvement. The client can be discharged from the hospital without ECT being effective. If a client exhibits a total change in behavior, the nurse should assess for suicidal thoughts.

What assessment findings would the nurse expect in a client with progressive myasthenia gravis? atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving muscle weakness, difficulty swallowing, double vision, and difficulty speaking muscle pain, difficulty speaking, headaches, and arthritic changes muscle inflammation, choking when eating, nearsightedness, and painful joints

muscle weakness, difficulty swallowing, double vision, and difficulty speaking With myasthenia gravis there is a disturbance in nerve transmission to the muscles. The signs and symptoms in this answer reflect this neuromuscular impairment. The other answers include signs and symptoms not related to neuromuscular impairment, such as atrophy, muscle inflammation, headaches, and arthritic changes.

A 35-year-old client diagnosed with multiple sclerosis three years ago presents the nurse with an advance directive refusing intubation, mechanical ventilation, and tube feedings. How should the nurse respond? "You should review this information with your healthcare provider at every admission." "Thank you for providing this document. I will make sure to keep the information between you and me." "Advance directives aren't necessary for a client your age in the early stages of multiple sclerosis." "Are you aware there are many new treatments for multiple sclerosis that could give good quality of life?"

"You should review this information with your healthcare provider at every admission." An advance directive should be part of the client's medical record. The client should review the document with the healthcare provider at every admission because some conditions may be reversible and temporary, making portions of the advance directive inappropriate. Advance directives should be shared with all members of the healthcare team and are appropriate for clients of any age. The nurse should not attempt to negate the client's wishes by mentioning new treatments.

A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? Place a cap over the client's head. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Immobilize the neck before the client is moved onto a stretcher. Administer a sedative as ordered.

Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan.

When caring for a client with myasthenia gravis, the nurse should assess the client for which manifestations of cholinergic crisis? Select all that apply. decreased secretions and saliva increased heart rate fasciculation ptosis respiratory rate of 6 breaths/min and irregular rhythm abdominal cramps

fasciculation (muscle twitch) ptosis respiratory rate of 6 breaths/min and irregular rhythm Cholinergic crisis is caused by overstimulation at the neuromuscular junction due to increased acetylcholine. The crisis affects the muscles that control eye and eyelid movement, causing fasciculation, ptosis (drooping eyelids), and difficulty chewing, talking, and swallowing. The muscles that control breathing and neck and limb movements are also affected, and respirations become slowed. Salivation is increased. The crisis is reversed with atropine.

The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which topic is most important to include in the plan? engaging in diversional activity maintaining a balanced nutritional diet enhancing the immune system maintaining a safe environment

maintaining a safe environment The primary focus is on maintaining a safe environment because the client with Parkinson's disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait commonly causes the client to fall or to have trouble stopping. The client should maintain a balanced diet, enhance the immune system, and enjoy diversional activities; however, safety is the primary concern.

A client recovering from Guillain Barré syndrome states, "I'm nervous that this disease will come back." Which nursing diagnoses is most suggested by this comment? risk for impaired breathing pattern anticipatory grief anxiety denial

anxiety Most clients with Guillain Barré syndrome recover completely, but anxiety is a common emotion. There is no indication that this client is denying having the disease. Anticipatory grief can occur before a loss. Risk for impaired breathing is a characteristic of Guillain Barré but does not address the client's fear.

A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction? "Signing an advance directive now will help ensure that my family and care team know what I want when I'm eventually unable to make decisions." "My family will take care of me. I've given my daughter durable power of attorney for health care." "I've signed the advance directive papers and will fight to maintain the highest quality of life until my time comes." "I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens."

"I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens." The client requires additional teaching if the client states that he/she will depend on the health care provider (HCP) to tell the family what to do in regards to his/her health. The client should be encouraged to make their own decisions regarding health care and to convey those wishes to family and the care team. The best way for the client to convey these wishes is to put them in writing in an advance directive. The client stating that an adult child has been designated to make health care decisions when the client cannot, that the client understands the purpose of an advance directive, or that the client has already signed an advance directive all suggest that client understands the importance of these legal documents in directing care.

The client with spinal cord compression due to a tumor is questioning the treatment that will be given. Which statement by the nurse is most accurate? "Antibiotics will be started to prevent infections that might result from treatment." "Radiation will shrink the tumor and relieve pressure on nerves and spine." "Corticosteroids will shrink the tumor, and you won't have to worry about it anymore." "Chemotherapy will shrink the tumor, and you will be cured."

"Radiation will shrink the tumor and relieve pressure on nerves and spine." The client will likely receive radiation as a local therapy initially to shrink the tumor and quickly relieve the pressure. Chemotherapy will shrink the tumor, but it is systemic and local treatment is needed initially. Additionally, chemotherapy may not cure the condition, so insisting that it will may be inaccurate. Corticosteroids are often used to decrease swelling associated with the tumor, but telling the client not to worry is nontherapeutic. Antibiotics are not indicated in this situation.

The nurse receives a physician's order to administer 1,000 mL of intravenous (I.V.) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.

31 The drip rate is calculated using the following formula: Volume of infusion (in milliliters)/Time of infusion (in minutes) × drip factor (in drops/milliliter) = drops/minute. Therefore, 1,000 mL/480 minutes × 15 drops/mL = 31 gtt/minute.

A nurse is preparing to administer phenytoin to a 99-lb (45-kg) client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be administered in the first dose? Record your answer as a whole number.

75 First, convert the client's weight to kilograms:99 lb ÷ 2.2 lb/kg = 45 kg.Then calculate the total daily dosage:45 kg X 5 mg/kg/day = 225 mg/day.Finally, divide the total daily dosage into three parts:225 mg/day ÷ 3 doses/day = 75 mg/dose.

A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which action is most important for the nurse to take to facilitate rehabilitation with eating? Have a family member assist with feeding at mealtimes. Assist the client in learning to eat with the left hand. Request a diet of thickened liquids that can be taken through a straw. Continue feeding the client until the hemiplegia resolves.

Assist the client in learning to eat with the left hand. It is important to involve the client in care. The client will need to learn to eat with the non-dominant hand. Promoting independence and supporting attainment of this skill will help the client positively meet the goal of rehabilitation. Feeding the client or having the family feed the client does not promote independence. The client is not having difficulty chewing or swallowing, so a thickened liquid diet is not needed.

The nurse is caring for a client with an injury to the thalamus. What information should the nurse include in the care plan? Give higher doses of pain medication. Avoid turning the client. Monitor the temperature of the bathwater. Keep patches on the client's eyes to prevent corneal abrasion.

Monitor the temperature of the bathwater. The nurse should monitor the temperature of the bathwater because the client cannot feel whether the water is too hot or too cold. Damage to the thalamus does not result in loss of the corneal reflex. Loss of position and vibratory sense usually occurs with degeneration of the posterior column of the spinal cord; therefore, turning every 2 hours is critical to prevent skin breakdown related to increased capillary pressure. The nurse can give only the prescribed dosage of pain medication.

Four hours after supratentorial surgery, the client is receiving IV fluid at 80 mL per hour, and the nurse is monitoring the client's neurological status using the Glasgow Coma Scale. At 1015, the client has turned to the left side and is lying flat. At 1030 the nurse notes the changes in the client's status (see chart.) What should the nurse do next? Slow the rate of the IV fluid to 60 mL per hour. Note the changes and continue to assess the client every 15 minutes. Position the client supine with the head of the bed at elevated at 30 degrees. Notify the surgeon of these findings.

Position the client supine with the head of the bed at elevated at 30 degrees. The Glasgow Coma Scale is used to determine the extent of neurological changes, which can include increased intracranial pressure. The decreases in this score are an early indicator of increasing ICP. The nurse should first position the client in the supine position with the head of the bed elevated at 30 degrees. A side lying position or having the head of the bed elevated beyond 30 degrees can decrease cerebral perfusion. Continued assessment and a more in-depth neurologic exam will help determine this. If repositioning the client improves the Glasgow score, the nurse does not need to contact the surgeon and should continue to monitor the client for changes. The nurse should determine the total amount of fluid intake before considering any action adjusting the fluid rate.

The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. What should the nurse do next? Dispose of the residual, and continue with the feeding. Withhold the tube feeding, and notify the health care provider (HCP). Readminister the residual to the client, and continue with the feeding. Delay feeding the client for 1 hour, and then recheck the residual.

Readminister the residual to the client, and continue with the feeding. Gastric residuals are checked before administration of enteral feedings to determine whether gastric emptying is delayed. A residual of less than 50% of the previous feeding volume is usually considered acceptable. In this case, the amount is not excessive and the nurse should reinstill the aspirate through the tube and then administer the feeding. If the amount of gastric residual is excessive, the nurse should notify the HCP and withhold the feeding. Disposing of the residual can cause electrolyte and fluid losses.

A new nurse has been assigned to the neurologic intensive care unit. Which client would be best to assign the nurse? A client: with a basilar skull fracture who has clear drainage coming from the nose with an astrocytoma who has just undergone a craniotomy admitted 2 hours ago with a headache and diagnosis of a ruptured aneurysm admitted 48 hours ago with bacterial meningitis who requires antibiotic administration

admitted 48 hours ago with bacterial meningitis who requires antibiotic administration The client with bacterial meningitis is in the most stable condition, so the nurse assigned to the neurologic intensive care unit should be assigned to this client. The nurse could also be familiar with the administration of antibiotics. The other clients require assessments and care from RNs who are more experienced in caring for clients with neurologic diagnoses.

The emergency department protocol provides for administration of alteplase (tPA) for clients with confirmed acute coronary syndrome (ACS). The nurse contacts the healthcare provider to clarify the order for the client with which health history? hypertension, dyslipidemia, and peripheral artery disease no previous history of cardiovascular disease atrial fibrillation and a mild stroke one month ago myocardial infarction one year ago with angioplasty

atrial fibrillation and a mild stroke one month ago Due to the risk of bleeding, a recent stroke (within 2 months) is an absolute contraindication to thrombolytic therapy. The nurse should hold the administration of alteplase (tPA) and notify the healthcare provider. The nurse should also check the client's history for anticoagulant use, which could also result in contraindication for tPA. Having had no previous history of cardiovascular disease or having the classic risk factors such as hypertension, dyslipidemia, and peripheral artery disease would not preclude the use of tPA nor would a past history of myocardial infarction with angioplasty a year ago.

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called sensorineural hearing loss. fluctuating hearing loss. conductive hearing loss. functional hearing loss.

conductive hearing loss. Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. The stapes must move freely for sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, preventing sound transmission. In a functional hearing loss, no organic lesion is found. Fluctuating hearing loss is a form of sensorineural hearing loss that varies over time. Sensorineural hearing loss affects the inner ear and involves the cochlea and eighth cranial nerve.

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis? risk for injury impaired urinary elimination imbalanced nutrition: less than body requirements ineffective airway clearance

ineffective airway clearance In parkinsonian crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of an ineffective airway clearance takes the highest priority. Although imbalanced nutrition: less than body requirements, impaired urinary elimination, and risk for injury are also appropriate nursing diagnoses, they are not immediately life-threatening.

A client has been diagnosed with an acute episode of angle-closure glaucoma. The client asks the nurse what will be done. What should the nurse tell the client about this health problem? Acute angle-closure glaucoma: is a medical emergency that can rapidly lead to blindness. is typically treated with sustained bed rest. frequently resolves without treatment. is most commonly treated with steroid therapy.

is a medical emergency that can rapidly lead to blindness. Acute angle-closure glaucoma is a medical emergency that rapidly leads to blindness if left untreated. Treatment typically involves miotic drugs and surgery, usually iridectomy or laser therapy. Both procedures create a hole in the periphery of the iris, which allows the aqueous humor to flow into the anterior chamber. Bed rest does not affect the progression of acute angle-closure glaucoma. Steroids are not a treatment for acute angle-closure glaucoma; in fact, they are associated with the development of glaucoma.

A client had a thrombotic cerebrovascular accident and now has flaccid hemiplegia of the right side. When can the health care team begin rehabilitation for this hospitalized client? after beginning anticoagulant therapy on admission the hospital as directed by the physical therapist when the client can work cooperatively with health care team

on admission the hospital Rehabilitation for a client who has sustained a cerebrovascular accident begins at the time the client is admitted to the hospital. The first goal of rehabilitation should be to help prevent deformities. This goal is achieved through such techniques as positioning the client properly in bed, changing the client's position frequently, and supporting all parts of the body in proper alignment. Passive range-of-motion exercises may also be started, unless contraindicated.

An older adult client in stage 2 of Parkinson's disease is being discharged with cellulitis of the right lower extremity. The nurse should base the discharge plan on which information? Select all that apply. The client has: difficulty communicating. potential for falls. decreased tissue perfusion. limited activity. risk for skin breakdown.

potential for falls. risk for skin breakdown. Usual aging is associated with dry skin; however, seborrhea (oily skin and dandruff) is one result of the biochemical changes associated with Parkinson's disease. The client with Parkinson's disease has a higher risk of skin breakdown due to the moist and oily skin. To maintain skin integrity, a client with Parkinson's disease needs frequent skin care and aeration of the skin. Gait instability in a client with Parkinson's disease is a result of muscle rigidity, change in the center of gravity, and gait shuffling. Because of these changes in gait and balance, the client is at higher risk for injuries in the environment, such as hitting furniture or obstacles in the client's path. As a result, the environment should be evaluated for potential injury or falls. Tissue perfusion and verbal communication are not problems typically associated with Parkinson's disease. The client should not experience activity intolerance from the cellulitis or Parkinson's disease.

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by touching the cornea with a wisp of cotton. introducing ice water into the external auditory canal. shining a bright light into the pupil. turning the client's head suddenly while holding the eyelids open.

turning the client's head suddenly while holding the eyelids open. To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III function; normally, the client's pupil responds by constricting.

A client is scheduled for a prostatectomy, and the anesthetist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse prepares the client according to the anesthetist's instructions. Which statement by the anesthetist would the nurse question? "Review the client's current medications, and verify the last dose of anticoagulants." "Position the client supine on the operating table, and prepare the site for injection." "Hold the client firmly in position while I administer the spinal block." "Obtain a set of vital signs, and connect the client to a continuous oxygen saturation monitor."

"Position the client supine on the operating table, and prepare the site for injection." The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and to ensure proper anesthetic distribution. The nurse would assist the client in a sitting or lateral position; lying supine is inappropriate as it obstructs the site of injection. Reviewing and verifying the last dose of anticoagulants will alert the nurse to a risk for bleeding. Obtaining vital signs is important to get baseline readings for comparison during and after the procedure. Since respiratory paralysis is a complication of subarachnoid injections, continuously monitoring the client's oxygen saturation is an appropriate intervention. Asking the nurse to hold the client firmly during the procedure will prevent sudden client movement that may displace the needle and cause injury to the nerve root.

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior? "Be patient. It takes time to adjust to such a massive loss." "Reviewing your losses is a way to help you work through your grief and loss." "Talking about the past is a form of denial. We have to help you focus on today." "It's a simple escape mechanism to go back and live again in happier times."

"Reviewing your losses is a way to help you work through your grief and loss." Spinal cord injury represents a physical loss; grief is the normal response to this loss. Working through grief entails reviewing memories and eventually letting go of them. The process may take as long as 2 years. Telling the client to be patient and that adjustment takes time is a clichéd type of response, one that is not empathetic or responsive to the client's needs. Telling the client to focus on today does not allow time for the grief process, which is necessary for the client to work through and adjust to the loss. The client is not escaping but is reminiscing on what is lost, to work through the grieving process.

Which is not a typical clinical manifestation of multiple sclerosis (MS)? double vision muscle tremors weakness in the extremities sudden bursts of energy

sudden bursts of energy With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report light flashes and floaters in front of the eye. headaches, nausea, and redness of the eyes. frequent episodes of double vision. a recent driving accident while changing lanes.

light flashes and floaters in front of the eye. The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts.

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which condition? pneumonia paralytic ileus renal failure meningitis

meningitis Head trauma and fractures place an individual at high risk for meningitis. A client who is febrile with increasing drowsiness should be investigated for posttraumatic meningitis. It is unlikely that pneumonia, renal failure, or a paralytic ileus would occur as a result of a basal skull fracture.

A nurse is educating a client recently diagnosed with early glaucoma. Which client statement indicates further teaching is necessary? "I will make sure to attend all my healthcare provider appointments." "I will increase fluid and fiber in my diet." "I will take my latanoprost eye drops as soon as I start to feel pain." "Glaucoma causes increased pressure in my eye, leading to vision problems."

"I will take my latanoprost eye drops as soon as I start to feel pain." Treatments for glaucoma include medicated eye drops that help drain fluid in the eye, thereby decreasing the intraocular pressure. Latanoprost is a prostaglandin agonist that should be administered daily. This medication is ineffective if the client takes it only when feeling pain. Constipation or straining to have a bowel movement can increase intraocular pressure; therefore clients should increase their fluids and fiber intake. It's important for the client to attend all healthcare provider appointments and get routine eye examinations to monitor the extent of the disease. Glaucoma presents with increased intraocular pressure that can damage the optic nerve, leading to visual disturbances.

The nurse has administered mannitol IV. Which is a priority assessment for the nurse to make after administering this drug? Assess for the presence of bowel sounds. Note serum calcium levels. Monitor urine output. Check the reaction of the pupils to light.

Monitor urine output. Mannitol is an osmotic diuretic used in acute clinical situations. It increases osmotic pressure and draws fluid into the vascular space. Monitoring hourly urine output is a priority nursing assessment when administering mannitol. Electrolyte levels should also be monitored, most specifically sodium, chloride, and potassium.Calcium levels are not affected by mannitol.Assessing for bowel sounds and checking pupil reaction to light are not priority nursing assessments when administering mannitol.

A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do? Notify the health care provider (HCP) of the client's breathing pattern. Increase the tidal volume on the ventilator. Count the rate to be sure that ventilations are deep enough to be sufficient. Increase the rate of ventilation.

Notify the health care provider (HCP) of the client's breathing pattern. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the HCP immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen, and the depth of breathing is assisted by the ventilator. The HCP will determine changes in the ventilator settings.

During morning care, a nurse notes that a client who's had a spinal cord injury has experienced a change in level of consciousness and isn't answering questions appropriately. The nurse checks the client's vital signs and measures the client's blood pressure at 180/110 mm Hg and heart rate at 125 beats/minute. The nurse determines that the client may be experiencing dysreflexia. What other assessments should the nurse make? Select all that apply. percentage of meals taken most recent bowel movement medications ordered for hypertension pain level urine output

most recent bowel movement pain level urine output The objective in treating a client with dysreflexia is to remove the triggering event and prevent complications. Common causes are distended bladder, constipation or impaction, skin stimulation, and pain. Percentage of meals taken isn't a priority assessment. Medications ordered for hypertension are of lesser priority than making assessments to identify the cause.

The nurse is to check a client's gag reflex. The most effective technique for testing the gag reflex is to: place a few milliliters of water on the client's tongue and note whether the client swallows. observe the client for evidence of spontaneous swallowing when the neck is stroked. touch the back of the client's throat with a tongue blade. observe the client's response to the introduction of a catheter for endotracheal suctioning.

touch the back of the client's throat with a tongue blade. The best technique for assessing the gag reflex is to touch the back of the client's throat in the pharyngeal area with a tongue blade or cotton swab. The reflex is absent if the client does not gag. Reflexes are typically absent or sluggish in the presence of increased intracranial pressure.Swallowing does not indicate the presence of a gag reflex.It is dangerous to place liquids in the mouth of a client with an unconfirmed gag reflex because of the risk of aspiration.Endotracheal suctioning does not test the client's gag reflex.