Quiz 8 review
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test?
"Are you taking any cardiac medications?"
A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include?
"Avoid driving until the medication's effects are evident." Rationale: Several CNS-related effects are common, including drowsiness, dizziness, headache, and confusion. Therefore, until the client knows how the medication will affect her, she should not drive a vehicle.
A nurse is caring for a client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the adolescent's parent is the priority for the nurse to address?
"He seems to be getting a lot more bumps and bruises lately." Rationale: When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is increased bruising. Although adolescent clients have increased rates of intentional and unintentional injury, carbamazepine can cause bone marrow suppression. The nurse should collect further data to determine whether the client could have thrombocytopenia and intervene to prevent bleeding.
Mr. Harrison, aged 49 has myasthenia gravis. Which of the following statements made by the client indicate poor understanding of myasthenic crisis?
"I should stay on bed most of the time."
A nurse is reinforcing discharge instructions with a client who has multiple sclerosis (MS). Which of the following instructions should the nurse include?
"Implement a schedule to include periods of rest." Rationale: The nurse should instruct the client to implement a schedule with periods of exercise followed by periods of rest to maintain muscle strength and coordination.
A nurse prepares to discharge a client with Alzheimer's disease. Which statements should the nurse include in the discharge teaching for this client's caregiver?
"Install deadbolt locks on all outside doors."
A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this client's teaching?
"Place a warm compress on your forehead at the onset of the headache."
A client has been diagnosed with organic brain pathology. Client is presenting with signs and symptoms total or partial loss of the ability to recognize familiar objects or people through sensory stimulation. This condition is called
Agnosia
The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities?
Eating a high fiber diet rather than using enemas or laxative supplements
Medication for Parkinson's disease is based on easing the signs and symptoms of the disease. Which medication's primary action is to increase levels of dopamine and levodopamine in order to improve voluntary motor nerve impulses?
Carbidopa-Leveodopa (Sinemet)
A client has a lumbar puncture, and the nurse is assessing the client after the procedure. What nursing observation would cause the nurse the most concern?
Clear fluid oozing form the puncture site
A client presents with a history of migraine headaches. Which subjective data is likely to be obtained either from the health history or during the physical examination to support the diagnosis? Select all that apply.
Client experiences unusual smells or sounds Fatigue and irritability Photosensitivity and diaphoresis Throbbing and pounding headache
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first?
Client with a Glasgow Coma Scale sore that was 10 and is now 8
A nurse is reinforcing teaching with a client who is taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?
Difficulty voiding Rationale: The nurse should instruct the client to report difficulty voiding as an adverse effect of benztropine, which may indicate urinary retention. Benztropine is an anticholinergic medication that helps decrease the rigidity and tremors of Parkinson's disease.
The nurse is caring for patient with multiple sclerosis. What appropriate nursing care should be implemented?
Encouraging a well-balanced diet high in fiber and adequate fluids
A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
Lethargy Rationale: An early manifestation of increased intracranial pressure is lethargy. The nurse should monitor and report any changes in the client's level of consciousness, such as restlessness or disorientation, because these are early manifestations of increased intracranial pressure.
The nurse is assisting a client with Parkinson's disease during mealtime. Which of the following action is inappropriate?
Limit the length of mealtime
A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?
Reduce stimuli. Rationale: The nurse should reduce stimuli by decreasing the number of visitors, remaining calm, and creating a quiet environment.
What is the advantage of giving Mannitol for patients with increased intracranial pressure?
Reduced cerebral edema by decreasing volume in the brain and extracellular fluid
A nurse is caring for a client who has epilepsy and has a new prescription for lamotrigine. For which of the following findings should the nurse instruct the client to withhold the medication and notify the provider?
Skin rash Rationale: Lamotrigine can cause several serious skin rashes, including Stevens-Johnson syndrome and others. The client should be instructed to notify the provider and withhold the medication if a skin rash develops.
A nurse enters a client's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?
Turn the client to a lateral position. Rationale: The greatest risk to this client is injury from aspiration; therefore, the first action the nurse should take is to turn the client to a lateral position, which helps prevent the tongue from obstructing the airway and allows drainage of secretions.
The nurse is assessing a 37-year-old client newly diagnosed with Multiple Sclerosis (MS). Which of the following symptoms would the nurse expect to find?
Vision changes
The nurse has received report on a group of clients. Which client requires the nurse's attention first?
Young adult who has experience four tonic-clonic seizures within the past 30 minutes
The client with known seizure disorder is now in her post ictal phase, the most appropriate nursing intervention at this phase is
provide restful environment and reorient as needed
The physician has ordered: 500 mL D5 1/2 NS over 3 hours for a client in the unit. What is the flow rate (mL/hr) required to deliver the prescribed amount? (Write numerical answer only; round to the whole number as appropriate.)
167
The nurse is monitoring an IV with NS infusing at 75 mL/hr using 20 gtt/mL macrodrip tubing. How many drops per minute is required to deliver the prescribed flow rate? (Write numerical answer only; round to whole number as appropriate.)
25
A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions?
A sensory warning that a seizure is imminent Rationale: n aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and may involve any of the senses. The client can report "hearing bells", "seeing lights", or "smelling something".
A client with Alzheimer's is admitted to the unit with urine and fecal incontinence, inability to ambulate and communicate. Which stage of the disease is this client experiencing?
Final/terminal stage
A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)?
Impairment of respiratory muscles
A nurse is collecting data from a client who has myasthenia gravis. Which of the following findings has the highest priority?
Ineffective breathing pattern Rationale: The greatest risk to this client is respiratory depression. Therefore, an ineffective breathing pattern is the highest priority finding.
Mr. Grouchy is to be discharged with phenytoin (Dilantin) therapy. Which of the following instructions should the nurse include in the discharge teaching?
Inform him not to stop the medication without prior approval from the physician
The client injured in an automobile accident, is being evaluated in the emergency department for possible head injury. Which test should not be done if there is an indication of increased intracranial pressure?
Lumbar puncture
An older female client with dementia is admitted to the Alzheimer's unit of an extended-care facility. The nurse knows that which characteristic is found in Alzheimer's disease that distinguishes it from other dementia?
Neurofibrillary tangles and plaques in the brain
The nurse is caring for a client who has suffered a severe closed head injury from a motor vehicle accident. In report, the nurse is told the client has a Glasgow Coma Scale value of 4. What would the nurse expect to find on the assessment of this client?
No intentional movement or response to stimuli
Progressive degenerative disorder of the basal ganglia: an eventual loss of coordination and control over involuntary motor movement is characteristic of which neurological disorders?
Parkinson's Syndrome
