Passpoint - Neurosensory Disorders

A client is admitted to the hospital after being involved in a motor vehicle accident. X-rays reveal that the client has a comminuted fracture of the left femur and a head laceration. A family member asks the nurse why opioid pain medication is not being administered for the client's pain. What is the best response by the nurse?

"A head injury is suspected, and the depressive effects of opioids will interfere with monitoring of neurologic function."

A client is scheduled for an electroencephalogram (EEG) after having a seizure for the first time. Which instruction does the nurse provide to the client as preparation for this test?

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

A quadriplegic client is prescribed baclofen, 5 mg by mouth three times daily. The client asks what is the indication for baclofen. How would the nurse respond?

"Baclofen is indicated when there are muscle spasms with paraplegia or quadriplegia from spinal cord lesions."

The nurse is discharging a client from the hospital after a laminectomy. What statement made by the client indicates that further education should be reinforced?

"I can't wait to toss my granddaughter up in the air."

A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?

"I'm sorry you haven't been bathed. I'm available to bathe you now."

The nurse assesses normal pupils in a client who had a craniotomy, and then writes "PERRLA" in the nurse's notes, along with other findings. The client asks what does the "E" stand for in this acronym? How would the nurse respond?

"It refers to your pupils and 'E' represents the word, 'Equal'."

A client with Parkinson disease tells the nurse of plans to take St. John's wort for depression in addition to the prescribed carbidopa-levodopa. What is the nurse's best response?

"St. John's wort can cause a toxic reaction with the Parkinsonian drugs."

A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response?

"The cause is unknown, and there are many environmental factors that may contribute to it."

A client is receiving pilocarpine eye drops. Which statement made by the client shows correct understanding of the medication?

"The medication will help decrease pressure in my eyes."

A hospitalized child is to receive 75 mg of acetaminophen for fever control. How much will the nurse administer if the acetaminophen concentration is 40 mg per 0.4 ml? Record your answer using two decimal places.

0.75

A client with a head injury, whose neck has been stabilized, is admitted to the hospital. In which preferred bed position would the nurse place this client?

30-degree head elevation

A client is diagnosed with a brain tumor. As the nurse is assisting the client from the bed to the chair, a generalized seizure occurs. Which action should the nurse perform first?

Assist the client to the floor, and place the client in a side-lying position.

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

The nurse is reinforcing education about the differences in bioavailability of different forms of phenytoin. Which statement would best benefit the client?

Avoid switching formulations without the primary health care provider's approval.

A client experienced a stroke that damaged the hypothalamus and was admitted to an acute unit. Which body function would the nurse anticipate that the client has problems with and assess as needed?

Body temperature control

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, the examination must be brief but will include which nursing intervention?

Evaluation of the corneal reflex response

A client is admitted with Ménière's disease. Which instruction should the nurse reinforce in client teaching?

Get up slowly, turning the entire body.

When contributing to the development of an education session on glaucoma for the community, which statement would the nurse emphasize?

Glaucoma can be painless with loss of peripheral vision.

The nurse is assisting a client with cerebrovascular accident (CVA) with feeding. Which nursing action(s) promote(s) safety when feeding the client? Select all that apply.

Have the client in a sitting position. Elevate the head of the bed. Check the mouth after feeding.

The nurse educator presents an in-service on how to formulate 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 educator will include in the lecture that the thermoregulatory centers are located in which part of the brain?

Hypothalamus

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 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.

A nurse is caring for a client with a closed head injury. What is the appropriate action by the nurse?

Notify the health care provider of a blood pressure change from 147/72 mm Hg to 176/70 mm Hg.

A client with breast cancer reports back pain and difficulty moving her legs. Which nursing intervention is most appropriate?

Notify the health care provider.

Which method should the nurse use to properly instill eardrops in an adult client with otitis externa?

Pull the pinna up and back.

A client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 mm Hg and heart rate of 50 beats/minute. Which nursing intervention should be done first?

Raise the head of the bed immediately to 90 degrees.

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

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

The nurse is reinforcing instruction with a female client regarding collection of a urine culture. Which instruction will the nurse include?

Separate the labia, one at a time clean from front to back with the three wipes provided in the kit, and then start to void in the toilet. Stop voiding, then continue to void into the sterile container.

The nurse is discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures?

activity of the brain

Which hormone deficiency should the nurse suspect as the underlying cause of diabetes insipidus in a postoperative craniotomy client?

antidiuretic hormone (ADH)

One hour after receiving pyridostigmine, a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the health care provider and prepares to administer which medication?

atropine

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 client is admitted with retinal detachment. Which sign or symptom would the nurse anticipate during data collection?

flashing lights and floaters

When obtaining the health history from a client with retinal detachment, the nurse expects the client to report:

light flashes and floaters in front of the eye.

The nurse is monitoring a client with a symptom of increased intracranial pressure (ICP) after head trauma. What observation does the nurse recognize as an early sign?

restlessness and confusion

A nurse is collecting data on a client who sustained a head injury after a fall from the roof. What signs and symptoms should the nurse observe the client for?

restlessness, disorientation, pupil dilation, and projectile vomiting

The health care provider suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. The nurse expects to find which factors in the client's history that are associated with myasthenia gravis? Select all that apply.

thymus gland hyperplasia hormonal changes

The nurse is gathering data from a client with Ménière disease. Which symptom does the nurse relate to the disease process?

tinnitus

A client with new-onset seizures of unknown cause is started on phenytoin, 750 mg IV now and 100 mg P.O. t.i.d. Which statement best describes the purpose of the loading dose?

to more quickly attain therapeutic levels