ATI: Med-Surge: Neurosensory
A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions? "I will sleep on the affected side." "I will avoid bending over." "I will restrict caffeine in my diet." "I will take aspirin to relieve my pain."
"I will avoid bending over." Rationale: The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can create intraocular hemorrhage.
A nurse is providing teaching to a client who is scheduled for an electroencephalogram in the morning? Which of the following pieces of information should the nurse share? "You'll feel some mild electrical sensations like static electricity during the procedure." "Do not eat or drink anything except water after midnight." "Shampoo your hair before the procedure and don't use any styling products afterward." "It's common to have temporary short-term memory loss after the procedure."
"Shampoo your hair before the procedure and don't use any styling products afterward." Rationale: An EEG is a painless test that records the electrical activity of the brain. For the test, the technician attaches electrodes to the scalp to record the tiny electrical charges released by nerve cells in the brain. For the electrodes to adhere to the scalp, the client's hair has to be clean and free of oil and hair-care products.
A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include? "You might need glasses after the surgery." "You may drive home after the procedure." "Continue to wear your contact lenses until the day of the surgery." "Expect complete healing and clear vision in about a week."
"You might need glasses after the surgery." Rationale: LASIK is a type of refractive laser eye surgery that ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or under correction of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.
A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? "You can expect your vision to return immediately after the procedure." "You should avoid reading for 1 week." "You can remove eye shields when you're sleeping." "You should not lift objects that weigh more than 25 lb."
"You should avoid reading for 1 week." Rationale: The client should avoid reading and any activity that can cause rapid eye movement of the eye due to the risk of detachment of the retina.
A nurse is preparing a client for an EEG. Which of the following pieces of information should the nurse share with the client? "Expect the test to take about 3 hr." "You'll begin by lying still with your eyes closed." "You'll sleep for the duration of the procedure." "Expect some mild electrical shocks during the test."
"You'll begin by lying still with your eyes closed." Rationale: The client will have to lie still in a reclining chair or bed and keep her eyes closed for the initial recording.
A nurse is caring for a client who has Ménière's disease. The nurse should identify that Ménière's disease affects which structure of the ear? Eustachian tube Cochlea Perichondrium Eardrum
Cochlea Rationale: Ménière's disease is a condition of the inner ear in which excess fluid distorts the inner ear canal system. The distortion decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system.
A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? Elevated glucose Elevated protein Presence of RBCs Presence of D-dimer
Elevated protein Rationale: An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include increased protein in the cerebrospinal fluid.
A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment? Inability to remember current age Inability to count backward Inability to locate eyeglasses Inability to recall names of family members
Inability to locate eyeglasses Rationale: Short-term memory loss is manifested by an inability to recall events or actions that just occured, such as where the client recently placed her eyeglasses.
A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside. Metered dose inhaler Continuous passive motion machine Oral-nasal suction equipment External defibrillator pads
Oral-nasal suction equipment Rationale: A client who has myasthenia gravis is at risk of aspiration due to progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.
A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? Finding the bathroom in the dark Driving at night Seeing numbers on highway signs Reading the newspaper
Reading the newspaper Rationale: With presbyopia, the lens is unable to change shape to focus on near objects. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens.
A nurse is caring for a client who has a dementia and is experiencing anxiety. Which of the following actions should the nurse take? Place a vest restraint on the client to protect others in the environment Provide a variety of routines to keep the client from getting bored Explain to the client that episodes of anxiety will decrease over time Redirect the client to a different activity with a small group of people.
Redirect the client to a different activity with a small group of people. Rationale: The nurse should redirect the client to another activity to distract from the anxiety. The client should not be exposed to a large group because this provides too much stimulation and can increase anxiety.
A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? Understanding speech Respiratory effort Decision-making ability Temperature control
Respiratory effort Rationale: The nurse should monitor understanding of speech for a client who has an injury to the temporal lobe of the brain.
A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding of the teaching? "An aura is a sensory warning that a seizure is imminent." "An aura is a continuous seizure in which seizures occur in rapid succession." "An aura is a period of sleepiness following the seizure." "An aura is a brief loss of consciousness accompanied by staring."
"An aura is a sensory warning that a seizure is imminent." Rationale: An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor.
A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? A TIA can cause irreversible hemiparesis A TIA can be the result of cerebral bleeding A TIA can cause cerebral edema A TIA can precede an ischemic stroke
A TIA can precede an ischemic stroke Rationale: TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include the loss of vision in an eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.
A nurse is caring for a client who has received sedation. When the nurse applies nail bed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the following? Confusion Arousal Orientation Attention
Arousal Rationale: The nurse should document that the client is demonstrating some degree of arousal. Withdrawing the hand in response to nail bed pressure indicates responsiveness to sensory stimulation.
A nurse in an Er is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? Depressed fracture of the forehead Clear fluid coming from the nares Motor loss on one side of the body Bleeding from the top of the scalp
Clear fluid coming from the nares Rationale: Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture.
A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? "Place a warm compress on your forehead." "Darken the lights." "Light a scented candle." "Drink a caffeinated beverage."
"Darken the lights." Rationale: The nurse should instruct the client to lie down in a dark room to reduce migraine pain.
A nurse is caring for a client who experienced a TBI. Which of the following findings indicates the client is experiencing increased ICP? Battle's sign Periorbital edema Dilated pupils Halo sign
Dilated pupils Rationale: Dilated pupils can indicate that ICP is increasing. This finding should be reported to the provider immediately.
A nurse is assessing a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve? Dizziness and hearing loss Weakness of a side of the tongue Facial droop and asymmetrical smile Loss of the same visual field in both eyes
Dizziness and hearing loss Rationale: Dizziness and hearing loss reflect alterations in the vestibulocochlear area, which CN VII innervates.
A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure. Reorient the client Protect the client's head Loosen constrictive clothing Turn the client onto his side
Protect the client's head Rationale: The nurse should apply the safety and risk reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. This client is at greatest risk for injury from hitting his head; therefore, the first action is to protect the client's head from injury.
During a neurological assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing? Remote Sensory Immediate Recall
Remote Rationale: The nurse tests remote or long-term memory by asking questions such as where and when the client was born, his age, when he graduated high school, and what the names, ages, and birth dates of his children are. The nurse can later verify this information with the client's family and friends.
A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? Multiple floaters Flashes of light in front of the eye Severe eye pain Double vision
Severe eye pain Rationale: Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headaches, brow pain, and nausea and vomiting.
A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? Swelling behind the affected ear Facial drooping on the affected side Nystagmus on the affected side Pearly gray color of the affected eardrum
Swelling behind the affected ear Rationale: Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear.
A nurse is reviewing the medical history of a client who is scheduled for a MRI examination of the cervical vertebra. Which of the following pieces of information in the client's history is a contraindication to this procedure? The client has a new tattoo The client is unable to sit upright The client has a history of peripheral vascular disease The client has a pacemaker
The client has a pacemaker Rationale: An MRI uses strong magnets and radio waves that are evaluated using computer technology to view 3-dimensional images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medical implants. Clients who have cerebral aneurysm clips, pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures.
A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? Add gestures when speaking with the client Ask open-ended questions Limit visitors to 3 at a time Use different words if the client does not understand a statement
Add gestures when speaking with the client Rationale: The nurse should ask questions when speaking with the client to increase the client's understanding of the conversation.
A nurse is providing teaching to a client who has a new diagnoses of Menière's disease. Which of the following instructions should the nurse include in the teaching? Avoid bearing down Increase caffeine intake Avoid sudden movements Increase sodium intake
Avoid sudden movements Rationale: Ménière's disease is a disorder of the inner ear affecting balance and hearing. It is characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.
A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions required the charge nurse to intervene? Visualizing the eardrum before irrigating Instilling 50 mL of fluid with each irrigation Using firm, continuous pressure while irrigating Warming the irrigation fluid to at least 98*F
Instilling 50 mL of fluid with each irrigation Rationale: When irrigating a client's ear, the nurse should use no more that 5 to 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in nausea, vomiting, or dizziness. The nurse should stop irrigating if the client expresses pain, nausea, vomiting, or dizziness.
A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (SATA) Place the client in respiratory isolation Monitor VSs every 2 hrs Monitor neuro status every 4 hr Maintain the client in a modified Trendelenburg position Keep the client's room darkened
Monitor VSs every 2 hrs Monitor neuro status every 4 hr Keep the client's room darkened Rationale: The nurse should monitor the client's VS to assess for changes consistent with increased intracranial pressure. In addition, the nurse should monitor the client's neuro status at least every 4 hours or more frequently if the client's status indicates. The course of encephalitis is unpredictable, so the client should be monitored closely for any indications of deteriorating neurological functioning. The nurse should provide the client with a low-stimulation environment to promote comfort and decrease agitation.
A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's VS, which of the following actions should the nurse perform next? Administer nifedipine Place the client in a high-Fowler's position Check for urinary retention Check for a fecal impaction
Place the client in a high-Fowler's position Rationale: According to evidence-based practice, the nurse should first place the client in a high-Fowler's position to decrease the client's BP and reduce the risk of end-organ damage from the sudden rise in BP.
A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils? Red tag Yellow tag Green tag Black tag
Black tag Rationale: The nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and indicate severely increased intracranial pressure. In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible.
A nurse asks a client ot stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg test, indicating which of the following alterations? Cerebellar dysfunction Occipital lobe dysfunction Increased intraocular pressure Macular degeneration
Cerebellar dysfunction Rationale: Cerebellar dysfunction causes a loss of position sense (proprioception), which results in a positive Romberg sign.
A nurse is teaching a client who has myopia about LASIK surgery. Which of the following is an adverse effect of LASIK surgery? Eyelid twitching Photosensitivity Intraocular hemorrhage Dry eyes
Dry eyes Rationale: LASIK surgery is a procedure that can correct nearsightedness, farsightedness, and astigmatism by changing the shape of the cornea. Adverse effects of LASIK surgery include dryness of the eyes and blurred vision.
A nurse is caring for a client who had a CVA. The client appears alert and engaged during a visit but does not respond verbally to questions. The nurse should document this as which of the following alterations? Expressive aphasia Dysarthria Receptive aphasia Dysphagia
Expressive aphasia Rationale: A client who has expressive aphasia understands speech but has difficulty speaking and writing. This typically occurs as a result of a lesion at Broca's area of the frontal lobe.
A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? Reduced left-sided motor function Difficulty with speech Impulsive behavior Neglect of the left side of the body
Difficulty with speech Rationale: The left hemisphere of the brain is usually the dominant side is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since the client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication.
A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? (SATA) Lost vision can improve with eye drops Administer eye drops as needed for vision loss Glasses will be necessary to correct the accompanying presbyopia Driving can be dangerous due to the loss of peripheral vision Laser surgery can help reestablish the flow of aqueous humor
Driving can be dangerous due to the loss of peripheral vision Laser surgery can help reestablish the flow of aqueous humor Rationale: Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen the canal of Schlemm.
A nurse is performing a neuro assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement? Dysphagia Positive Babinski sign Decreased deep-tendon reflexes Ataxia
Dysphagia Rationale: Dysphagia can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).
A nurse is caring for a client during the first 72 hr following a CVA. Which of the following actions should the nurse take? Turn the client's head to the side with the head of the bed elevated 60* Place the head of the bed flat with pillows inde the client's neck and feet Elevate the head of the bed 25* to 30* with the client in neutral midline position Position the client in a dorsal recumbent position with pillows under the head and knees
Elevate the head of the bed 25* to 30* with the client in neutral midline position Rationale: Elevating the head of the bed 25* to 30* with the client's head in a neutral midline position helps to prevent an increase in intracranial pressure. Increased intracranial pressure is a major risk factor for complications in the first 72 hours following the onset of a CVA
A nurse is caring for a client who has had repeated middle ear infections. The client reports that the provider said the infections are due to an obstruction of the structure that connects the middle ear to the throat. The nurse should identify that the provider was referring to which of the following structures? Oval window Auricle Tympanic membrane Eustachian tube
Eustachian tube Rationale: The eustachian tube connects the middle ear to the throat and allows equalization of pressure and drainage of fluids from the middle ear into the throat.
A nurse is caring for a client who has a hearing impairment. Which of the following actions should the nurse take when communicating with the client? Face the client when speaking Speak in a loud voice Use a normal rate when speaking Avoid hand motions
Face the client when speaking Rationale: Facing the client will allow the client to observe the nurse's facial expressions and to lip read during the communication process.
A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching? High-pitched sound in the ear Intermittent rapid eye movement Itching of the external canal Feeling of fullness in the ear
Feeling of fullness in the ear Rationale: A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations include ear pain, a cracking sound when yawning or swallowing, and mild dizziness.
A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? Occipital Temporal Frontal Limbic
Frontal Rationale: The nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thoughts.
A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? Have the client open his mouth and say, "aah" Ask the client to identify the scent of coffee Use a tongue blade to provoke a gag reflex Have the client smile and raise his eyebrows
Have the client open his mouth and say, "aah" Rationale: The vagus or X nerve has both sensory and motor functions. To test the motor function, the nurse should have the client open his mouth and say, "aah." The palate and the uvula should move upward in response. The nurse should also assess the client's voice quality for hoarseness.
A nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. Which of the following findings indicates a therapeutic effect of this medication? Decreased blood glucose Decreased bronchospasms Increased urine output Increased temperature
Increased urine output Rationale: Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this medication.
A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching? Dry the ear canal with a cotton swab after swimming Apply an ice pack to the ear to relieve pain Instill a diluted alcohol solution into the ear after swimming Irrigate the ear with cool tap water to clean
Instill a diluted alcohol solution into the ear after swimming Rationale: External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal.
A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status? Vital signs Body posture Level of consciousness Examination of pupils
Level of consciousness Rationale: When applying the urgent vs. nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose more of a risk to the client. The nurse might also use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify the most urgent finding. Therefore, the priority assessment is level of consciousness. A change in the client's LOC can be the first indication of a change in neuro status.
A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease (AD). Which of the following pieces of information should the nurse include in the teaching? Place abstract pictures on the wall in the client's room Provide music for the client using headphones Reorient the client to reality frequently Limit choices offered to the client
Limit choices offered to the client Rationale: Choices should be limited for a client who has stage II AD to reduce confusion and frustration.
A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care? Prevent depression in the client Refer the client to occupational therapy Support the client's family Monitor the client for intracranial pressure (ICP)
Monitor the client for intracranial pressure (ICP) Rationale: The greatest risk to this client is an injury from increased ICP, which can result in decreased cerebral perfusion and neurological injury. Therefore, the priority intervention the nurse should include in the plan of care is monitoring the client for increased ICP. Manifestations of increased ICP include a decreased LOC and ac change in pupils.
A nurse is providing discharge teaching to a client who has had a transient ischemic attack (TIA). Which of the following instructions should the nurse include? Reduce dietary sodium Decrease dietary potassium Restrict intake of insoluble fiber Limit alcohol intake to <3 servings per day
Reduce dietary sodium Rationale: A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should limit sodium intake to help control hypertension and prevent future TIAs.
A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? Flushing of the lower extremities Hypotension Tachycardia Report of a headache
Report of a headache Rationale: Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.
A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? Glaucoma Retinal detachment Macular degeneration Cataracts
Retinal detachment Rationale: A flash of light and a sudden loss of vision are manifestations of retinal detachment. Clients report the event of vision loss as sudden and painless.
A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this might have which of the following disorders? Cataracts Angle-closure glaucoma Retinal detachment Macular degeneration
Retinal detachment Rationale: The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral vision or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field.
A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? Spasticity of the left foot Negative Babinski reflex Ocular hypertension Right-sided hemiplegia
Right-sided hemiplegia Rationale: The nurse should expect right-sided hemiplegia following intracranial bleeding in the left hemisphere of the brain.
A nurse is caring for a client who has a closed TBI and is experiencing increased ICP. This increase in ICP is due to which of the following? Decreaed cerebral perfusion Leakage of cerebral spinal fluid Rigid skull containing cranial contents Brain herniated into the brainstem
Rigid skull containing cranial contents Rationale: The nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP.
A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following pieces of information in the client's medical record should the nurse identify as a risk factor for tinnitus? Use of hydrochlorothiazide Chronic use of acetaminophen Allergic external otitis Sclerosis of the ossicles
Sclerosis of the ossicles Rationale: Sclerosis of the ossicles, called otosclerosis, is an overgrowth of the tissue of the bones in the middle ear, which can cause tinnitus and conductive hearing loss. A stapedectomy is a surgical procedure that corrects otosclerosis by removing a portion of the stapes and inserting a prosthesis.
A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? Trendelenburg Prone Semi-Fowler's Sims'
Semi-Fowler's Rationale: To prevent an increase in ICP, the nurse should position the client with his head midline and the head of the bed elevated 30*. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased ICP.
A nurse is caring for a client who has a TBI and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? The client rigidly extends his arms The client internally flexes his wrists The client curls into a fetal position the client internally rotates his legs.
The client rigidly extends his arms Rationale: A client who exhibits a decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline.
A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? The client's ability to clear oral secretions The client's ability to communicate verbally The client's ability to move all extremities The client's ability to remain continent of urine
The client's ability to clear oral secretions Rationale: The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check the client's ability to clear secretions in order to protect the airway and reduce the risk of aspiration.
A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? Widened pulse pressure Tachycardia Periorbital edema Decrease in urine output
Widened pulse pressure Rationale: A widening of the pulse pressure is a manifestation of increased ICP. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting.
A nurse in the ER is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first? A client who is difficult to arouse and is unable to respond to questions A client who has slurred speech and exhibits anger A client who reports nausea and vomiting A client who is uncooperative and has uncoordinated movements
A client who is difficult to arouse and is unable to respond to questions Rationale: The nurse should apply the safety and risk-education priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. A client who is difficult to arouse and is unable to respond to questions could have a decreased level of consciousness due to an alcohol intoxication level of 401-800 mg/dL or traumatic brain injury. The greatest risk to this client is the neurological sequelae of head trauma or death due to severe alcohol intoxication.
A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? Pupils nonreactive to light Opacity visible behind the pupil White circle around the outside border of the iris Increased intraocular pressure
Opacity visible behind the pupil Rationale: With a cataract, the lens of the eye becomes thick and opaque with age and appears as opacity behind the pupil when the nurse shines a light on the area.
A nurse is providing teaching to a client who has a new diagnosis of MS. The client asks the nurse about the usual cause of MS. Which of the following should the nurse make? "Each client is different; we cannot predict what will happen." "I can see that you are worried, but it's too soon to predict what will happen." "Acute episodes are usually followed by remissions, which can vary in duration." "It's too early to think about the future; let's focus on the present and take each day as it comes."
"Acute episodes are usually followed by remissions, which can vary in duration." Rationale: This client is asking an information-seeking question, so the nurse should provide the client with factual information. The nurse should inform the client that MS is a chronic autoimmune disorder characterized by remissions and exacerbations, with exacerbations becoming more frequent and intense as the disease progresses.
A nurse is preparing a client for an EEG. When the client asks the nurse what this test does, which of the following responses should the nurse provide? "An EEG measures the electric signals to your brain from hearing, sight, and touch." "An EEG measures the electrical activity in your muscles." "An EEG identifies the magnetic fields produced by electrical activity in your brain." "An EEG records the electrical activity of your brain cells."
"An EEG records the electrical activity of your brain cells." Rationale: An EEG measures brain waves via multiple electrodes the technician will attach to the scalp. An EEG provides information the provider can use to identify various problems, including seizure disorders, sleep disorders, inflammation, bleeding, and migraine headaches.
A nurse is teaching a client about computed tomography (CT) scanning of the brain. Which of the following teaching points should the nurse include? "You'll have to lie very still on a long, narrow table during the test." "You should be able to sit up during the test if you need to have a break." "You'll have many tiny electrodes placed on your scalp during the test." "You should expect the test to take at least an hour."
"You'll have to lie very still on a long, narrow table during the test." Rationale: The nurse should inform the client that the test will require the client to lie very still on a long, narrow table. Movement during the test interferes with the quality of the films.
A nurse is preparing an older adult client who had a transient ischemic attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters at home? Blood glucose Blood pressure Daily weight Sensation in the feet
Blood pressure Rationale: A temporary disturbance of the blood supply to the brain causes a TIA, which is a brief alteration in neurological function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track hos BP regularly to promote hypertension management and reduce the risk of another TIA or cerebrovascular accident.
A nurse responds to a call from an assistive personnel that a client just had a seizure and is unconscious. Which of the following assessments is the nurse's priority? Measure the client's VS Perform a neuro exam Check airway patency Assess the client for injuries
Check airway patency Rationale: The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning; having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The priority assessment the nurse should make is to check the client's airway patency. The nurse should establish and maintain the client's airway to prevent respiratory arrest and hypoxia.
A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? Orthopnea Cheyne-Stokes Paradoxical Kussmaul
Cheyne-Stokes Rationale: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.
A nurse is assessing an older adult client for physiological changes that can occur with age. Which of the following findings should the nurse expect? Increased saliva production Decreased sense of taste Increased sense of smell Decreased chest wall rigidity
Decreased sense of taste Rationale: When assessing an older adult client, the nurse should expect a decreased sense of taste due to atrophy of the taste buds. This can increase the client's risk for poor intake, resulting in less than optimal nutrition.
A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan? No food or fluids consumed for 4 hours Difficulty recalling recent events Development of hives when eating shrimp Paresthesia in both hands
Development of hives when eating shrimp Rationale: An allergy to shellfish is a contraindication for use of contrasts media during a CT scan. The nurse should inform the provider and explain to the client that this factor might alter how the technician performs the CT scan.
A nurse is providing teaching about degenerative complications to the partner of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority? Dysphagia Emotional lability Impaired speech Self-care dependency
Dysphagia Rationale: The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and should be the nurse's priority concern. When appyling the ABC priority-setting framework, the airway is the priority because it must be open for oxygen exchange to occur. Breathing is the second priority framework because adequate ventilatory effort is essential for oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, dysphagia is the priority manifestation because it can lead to aspiration.
A nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? Wernicke's area Cerebral cortex Basal ganglia Hypothalamus
Hypothalamus Rationale: The nurse should identify that the hypothalamus, located below the cerebrum of the brain, is responsible for the regulation of body temperature.
A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. After 5 min, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory? Remote Sensory Immediate Recall
Immediate Rationale: The nurse tests the client's immediate or new memory by following the 3-object protocol. A client without cognitive decline should be able to recall and name the objects 5 minutes later.
A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? Question the client's coworkers about the mechanism of injury Check the client's pupils for equality and reaction to light Measure the client's alertness using the Glasgow Coma Scale Immobilize the client's cervical spine
Immobilize the client's cervical spine Rationale: The greatest risk to this client is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury. Therefore, the priority action the nurse should take after assessing the client's ABC is immobilizing the client's neck with a cervical collar. A client who has head trauma might also have damage to the cervical spine. This is an essential component of the initial stabilization of a client who has a head injury.
A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety? Initiate seizure precautions Ensure the client receives a soft diet Provide an obstacle-free path for ambulation Instruct the client to use lukewarm water when showering
Provide an obstacle-free path for ambulation Rationale: Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve II is the optic nerve; therefore, the client has at least some visual challenges and will need an obstacle-free path for ambulation.
An ER nurse is assessing a client who has a new TBI. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? Monitor urinary output Administer an osmotic diuretic Provide supplemental oxygen Initiate seizure precautions
Provide supplemental oxygen Rationale: The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death.
During a neuro assessment, a nurse asks how the client arrived at the appointment and with whom. Which of the following types of memory is the nurse testing? Remote Immediate Recall Past
Recall Rationale: To test recall or recent memory, the nurse should ask the client to provide details about how he arrived at the appointment and with whom. The nurse could also ask the client to name any health care providers he saw in the past few days.
A home health nurse is interviewing the adult child of a client who has Alzheimer's disease. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Which of the following referrals should the nurse make for the caregiver? Attorney Physical therapy Respite care Occupational therapy
Respite care Rationale: The nurse should make a referral for respite care for the caregiver. Respite care can provide needed relief for caregivers in an expedient, short-term agreement.
A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of information should the nurse include? Use enemas to treat constipation caused by daily medication Take a hot bath when muscles ache Eat a low-calorie diet Set an alarm to ensure medication dosages are taken on time
Set an alarm to ensure medication dosages are taken on time Rationale: The nurse should instruct the client to take the medication dosages on time to maintain a therapeutic blood level. Dosages should not be missed or postponed because this can cause an exacerbation of the disease.
A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? BUN Blood glucose Urine ketones Specific gravity
Specific gravity Rationale: DI is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, an infection, or a tumor. In this condition, an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (100.01 to 1.003) is a manifestation of DI.
A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client? The client cannot name simple objects or formulate sentences or phrases The client has difficulty articulating correctly due to muscle weakness of the mouth and tongue The client is unable to understand words or sentences she hears The client speaks words that substitute for those she intends to say
The client is unable to understand words or sentences she hears Rationale: Clients who cannot understand words or sentences they hear have receptive aphasia.
A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of ICP. Which of the following findings indicates that the medication is having a therapeutic effect? The client's serum osmolarity is 310 mOsm/L The client's pupils are dilated The client's HR is 56/min The client is restless
The client's serum osmolarity is 310 mOsm/L Rationale: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.
A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard EEG. Which of the following instructions should the nurse include in the teaching? Remain NPO 6 to 8 hours to the EEG Take a sedative the night prior to the EEG Thoroughly shampoo her hair prior to the EEG Sleep for at least 8 hours during the night prior to the test
Thoroughly shampoo her hair prior to the EEG Rationale: The nurse should instruct the client to thoroughly wash her hair prior to the EEG because hairsprays, oils, and other hair preparations interfere with recording results of the EEG.
A nurse is walking along the unit when she sees smoke coming from the central supply room. After activating the fire alarm, which of the following actions should the nurse take? Place unused equipment between the fire doors Turn off the sources of oxygen near the fire Place rolled blankets at the base of the fire Keep the doors to the unit and client rooms open
Turn off the sources of oxygen near the fire Rationale: Oxygen fuels fire, so the nurse should turn off all sources of oxygen near the fire.
A nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. Which of the following actions should the nurse take? Insert an oral airway Turn the client onto a side Restrict movement of the client's limbs Place a pillow under the client's head
Turn the client onto a side Rationale: The nurse should turn the client onto a side to protect the client from aspiration.
A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following findings is an early manifestation of ALS? Sensory dysfunction Weakness of the distal extremities Decreased vision Altered temperature regulation
Weakness of the distal extremities Rationale: ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord, causing muscle wasting, spasticity, and eventually paralysis. Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet), speech, swallowing, and breathing.
A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect? Tonic-clonic seizures Report of a severe headache Weakness of the lower extremities Decreased LOC
Weakness of the lower extremities Rationale: Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.
