Neurosensory passpoint

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:

increase the frequency of the catheterizations.

On the 5th postoperative day, a client who underwent spinal fusion begins to complain of nausea and has an episode of vomiting. How should a nurse intervene?

Auscultate the abdomen for bowel sounds.

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?

Assist the client to a side-lying position on the floor, and protect her with linens.

The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first?

Call the physician immediately.

The nurse is performing a mental status examination on a client diagnosed with a subdural hematoma. This test assesses which of the following functions?

Cerebral function

The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?

Elevate the head of the bed to 30 degrees.

A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin (Dilantin) to control seizures, the nurse assesses for which common adverse drug reaction?

Excessive gum tissue growth

A client injured in a train derailment is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

hypoxia.

The nurse is caring for a client with an acute bleeding cerebral aneurysm. The nurse should take all of the following steps except:

keep the client in one position to decrease bleeding.

The nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy.

After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?

Perform a lumbar puncture.

When caring for a client with a head injury, the nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Rising blood pressure and bradycardia

How should the nurse position a client for a lumbar puncture?

Laterally, with knees drawn up to the abdomen and chin touching the chest

A client who's receiving phenytoin (Dilantin) to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?

10 to 20 mcg/ml

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention would reduce the client's risk of increased intracranial pressure (ICP)?

Administering a stool softener as prescribed

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

Attaching braces or splints to each foot and leg

A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints?

Fasten the restraint to the bed frame using a quick-release knot.

A client is receiving an I.V. infusion of mannitol (Osmitrol) 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 the most significant?

Increased urine output

What is the function of cerebrospinal fluid (CSF)?

It cushions the brain and spinal cord.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Notify the physician.

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Client teaching about this drug should include which instruction?

"Schedule follow-up visits with your physician for blood tests."

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. What should the nurse tell the client about the paralysis?

"The paralysis caused by this disease is temporary."

A client who sustained a closed head injury in a motor vehicle accident is diagnosed as brain dead by a neurosurgeon. The physician has scheduled a meeting with the client's family about discontinuing life support. Before the meeting, a family member asks the nurse her opinion about life support. Which response by the nurse is appropriate?

"What has the physician explained about the client's prognosis?"

A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate?

"What has your physician told you about your ability to walk again?"

For a client with a head injury whose neck has been stabilized, the preferred bed position is:

30-degree head elevation.

A client with quadriplegia is in spinal shock. What should the nurse expect?

Absence of reflexes along with flaccid extremities

A nurse is caring for a group of clients on the neurologic unit. Which task should the nurse perform first?

Arrange an escort for a client who needs to go to the physical therapy department.

A client injures his spinal cord in a diving accident. The nurse knows that the client will be unable to breathe spontaneously if the injury site is above which vertebral level?

C4

A client who experienced a stroke that left her with residual right-sided weakness was just discharged to go home. The client lives in a two-story house in which the bathroom is located on the second floor. A home health care nurse is visiting the client for the first time. Which issue should the nurse address during this visit?

Client's ability to climb the stairs while using a walker

The nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?

Establishing an intermittent catheterization routine every 4 hours

After a motor vehicle accident, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?

Flat, except for logrolling as needed

Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?

In 10 to 15 minutes

When obtaining the vital signs of a client with multiple traumatic injuries, the 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)

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern

The physician prescribes diazepam (Valium), 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true?

It should be administered no faster than 5 mg/minute in an adult.

A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?

Risk for injury

The parents of a client who sustained a closed head injury in a motor vehicle accident voice their concerns about the distance and cost of the rehabilitation center chosen for their son. Which health care team member can help the parents with their questions and concerns?

Social worker

The physician prescribes mannitol (Osmitrol) I.V. stat for a client who develops increased intracranial pressure after a head injury. While preparing to administer mannitol, the nurse notices crystals in the solution. What should the nurse do?

Warm the solution in hot water to dissolve the crystals.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move him to a flat surface and turn him on his side.

A client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?

Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

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?

Elevated 30 degrees

After a stroke, a 75-year-old client is admitted to a health care facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which action is a priority for this client?

Elevating the head of the bed to 30 degrees

While bathing a client who sustained a stroke, a nurse is asked by a coworker to assist with repositioning another client. What should the nurse do?

Ensure the client's privacy, put up the side rail, and explain that she'll return shortly.

A client undergoes cerebral angiography to evaluate for neurologic deficits. 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)

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects which neuromuscular blocking agent to be administered?

Succinylcholine (Anectine)

A client is having a tonic-clonic seizure. What should the nurse do first?

Take measures to prevent injury.

When caring for a client with head trauma, the nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do?

Test the nasal drainage for glucose.

The nurse is performing a neurologic assessment on a client with a head injury. To assess the Babinski reflex, where would the nurse initially place the tongue blade?

To test for the Babinski reflex, the nurse should use a tongue blade to slowly stroke the lateral side of the underside of the foot. Start at the heel and move towards the great toe.

The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal?

Urine retention or incontinence

(SELECT ALL THAT APPLY) A client with tonic-clonic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Which instructions about phenytoin should the nurse give this client?

(1) Monitor for skin rash., (3) Perform good oral hygiene, including daily brushing and flossing., (4) Periodic follow-up blood work is necessary., (5) Report to the physician problems with walking and coordination, slurred speech, or nausea.

(SELECT ALL THAT APPLY) A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture?

(2) Wrist pronation, (3) Stiff extension of the arms and legs, (4) Plantar flexion of the feet (5) Opisthotonos

The nurse on the neurologic unit must provide care for four clients who require different levels of care. Which client should the nurse assist first with morning care?

A client who requires minimal bathing assistance and ambulates with a walker independently

A client is thrown from an automobile during a collision. The nurse knows that the client will be able to maintain gross arm movements and diaphragmatic breathing if the injury occurs at what vertebral level?

C5

A client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

Lidocaine (Xylocaine)

A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?

Make arrangements for the client to receive information about advance directives.

A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do?

Make sure a tonsil suction device is readily available while providing mouth care.

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. What does this mean?

Muscle contraction is palpable and visible.

A quadriplegic client is prescribed baclofen (Lioresal), 5 mg by mouth three times daily. What is the principal indication for baclofen?

Muscle spasms with paraplegia or quadriplegia from spinal cord lesions

A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based on these findings, which action should the nurse take?

Notify a physician of the findings.

During the course of a busy shift, a nurse fails to document that a client's ventricular drain had an output of 150 ml. Assuming that the drain was no longer draining cerebrospinal fluid, the physician removes the drain. When the nurse arrives for work the next morning, she learns that the client became agitated during the night and his blood pressure became elevated. What action should the nurse take?

Notify the physician of the documentation omission.

The nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness.

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

elevate the head of the bed 90 degrees during meals.

A nurse on the neurologic unit evaluates her client care assignment after receiving the shift report. Which client in her assignment should she attend to first?

A client who sustained a fall on the previous shift and is attempting to get out of bed

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 does Brudzinski's sign indicate?

Meningeal irritation

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?

Obesity

A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

A 70-year-old client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which of the following objectives is appropriate?

Promoting weight-bearing exercises

The nurse observes that a comatose client's response to painful stimuli is decerebrate posturing. The client exhibits extended and pronated arms, flexed wrists with palms facing backward, and rigid legs extended with plantar flexion. Decerebrate posturing as a response to pain indicates:

dysfunction in the brain stem.

The nurse is teaching a client with a T4 spinal cord injury and paralysis of the lower extremities how to transfer from the bed to a wheelchair. The nurse should instruct the client to move:

his upper body to the wheelchair first.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

place the client on his side, remove dangerous objects, and protect his head.

For a client with suspected increased intracranial pressure (ICP), the most appropriate respiratory goal is to:

promote carbon dioxide elimination.

A client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg by mouth twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:

treatment of spasticity associated with spinal cord lesions.

The nurse formulates a nursing diagnosis of Risk for imbalanced body temperature for a client who suffers a stroke after surgery. The expected outcomes incorporate assessment of the client's temperature to detect abnormalities. The thermoregulatory centers are located in which part of the brain?

Hypothalamus

(SELECT ALL THAT APPLY) A client is admitted to the medical-surgical unit after undergoing intracranial surgery to remove a tumor from the left cerebral hemisphere. Which nursing interventions are appropriate for the client's postoperative care?

(2) Turn the client on his right side., (5) Apply a soft collar to keep the client's neck in a neutral position.

A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

The client uses a mirror to inspect his skin.

If a client experienced a stroke that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

body temperature control.

(SELECT ALL THAT APPLY) A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client?

(1) Assist the client to the floor., (2) Turn the client to his side., (3) Place a pillow under the client's head.

A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?

An isolation room close to the nurses' station

The neurologic unit has identified a 30% occurrence of pressure ulcers in clients admitted with the diagnosis of stroke. Which of the following actions should be included in the unit's performance improvement plan?

Creating a spreadsheet on which nursing staff should document repositioning of clients admitted with a stroke

A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then he became alert and behaved as though nothing had happened." Shortly afterward, he 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 would expect to observe which sign first?

Declining level of consciousness

The nurse is planning care for a client who suffered a stroke in the right hemisphere of his brain. What should the nurse do?

Provide close supervision because of the client's impulsiveness and poor judgment.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority?

Risk for injury related to neurologic deficit