Neurosensory Prep-U (EXAM 4)

To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:

coughing.

For a neurologically injured client, the nurse would best assess motor strength by:

Comparing equality of hand grasps.

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply.

• "I'll try to chew my food on the unaffected side." • "Drinking fluids at room temperature should reduce pain." • "If brushing my teeth is too painful, I'll try to rinse my mouth instead."

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.

• Elevate the head of the bed 15 to 20 degrees. • Contact the health care provider (HCP) if ICP is greater than 15 mm Hg. • Monitor neurologic status using the Glasgow Coma Scale.

A client with an inoperable brain tumor is brought to the hospital because the family can no longer care for the client at home. As the nurse provides care for the client, family members express their disappointment at not being able care for him/her at home as the client wished, since he/she did not want to die in the hospital. Which response by the nurse is best?

"Have you explored hospice care? I can ask the case manager to discuss this care option with you, if you're interested."

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 can participate in sexual activity but might not experience orgasm."

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 am I unable to 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?

"Reviewing your losses is a way to help you work through your grief and loss."

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.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

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?

Administer stool softeners.

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)?

Administering a stool softener as ordered

Which of the following interventions would likely be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery?

Applying ice compresses.

Which of the following is contraindicated for a client with seizure precautions?

Assessing oral temperature with a glass thermometer.

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 of the following actions is most important for the nurse to take to facilitate rehabilitation with eating?

Assist the client in learning to eat with the left hand.

Which of the following nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?

Disorientation, increasing blood pressure, bradycardia, and bradypnea

When completing a nursing assessment on a client admitted with a neck injury, which of the following findings would indicate an incomplete spinal cord injury (SCI)?

Evidence of voluntary motor and sensory function below the level of injury

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for:

Expressive aphasia.

The nurse has administered mannitol I.V. Which of the following is a priority assessment for the nurse to make after administering this drug?

Monitor urine output.

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.

Which goal is a priority for a client who has undergone surgery for retinal detachment?

Prevent an increase in intraocular pressure.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

After the client returns from surgery for a deviated nasal septum, the nurse should place the client in what position?

Semi-Fowler's.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?

XII

A nurse is caring for a female client following a motor vehicle accident resulting in paraplegia. The client is ready for discharge to home with her husband, who states, "I'm scared to carry her because I'm afraid I'll either hurt my back or drop her." A nurse identifies a need for discharge teaching of the husband in regard to:

ergonomic principles and body mechanics.

The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:

monitor the temperature of the bathwater. Rationale: thalamus controls sensory perception