ATI Questions/Answers Neuro

B. Instilling 50 mL of fluid with each irrigation When irrigating a clients ear, the nurse should use no more than 5-10mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear.

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? B. Instilling 50mL of fluid with each irrigation

C. Respite Care 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 arrangement.

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? C. Respite Care

A. Cerebellar dysfunction Cerebellar dysfunction causes a loss of position sense (proprioception), which results in a positive Romberg sign.

A nurse asks a client to 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? A. Cerebellar dysfunction

C. Instill a diluted alcohol solution into the ear after swimming.

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? C. Instill a diluted alcohol solution into the ear after swimming.

B. Difficulty with speech The left hemisphere of the brain is usually the dominant side and is responsible for language.

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? B. Difficulty with speech

C. Oral-nasal suction equipment A client who has myasthenia gravis is at risk of aspiration due to progressive weakness of the oropharyngeal muscles. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.

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? C. Oral-nasal suction equipment

B. Clear fluid coming from the nares. Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture.

A nurse in an emergency department 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? B. Clear fluid coming from the nares.

D. Immobilize the client's cervical spine. The greatest risk to this client is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury. Therefore, after ABC's priority is immobilization of clients neck with cervical collar.

A nurse in the ED 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? D. Immobilize the client's cervical spine.

A. A client who is difficult to arouse and is unable to respond to questions. A client who is difficult to arouse and is unable to respond to questions could have decreased LOC due to alcohol intoxication level 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 in the emergency department 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. A client who is difficult to arouse and is unable to respond to questions.

C. Weakness of the lower extremities Guillain-Barre syndrome also called acute inflammatory demyelinating, 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.

A nurse is assessing a client who has Guillain-Barr'e Syndrome. Which of the following findings should the nurse expect? C. Weakness of the lower extremities

B. Opacity visible behind the pupil 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 assessing a client who has cataracts. Which of the following findings should the nurse expect? B. Opacity visible behind the pupil.

B. Cheyne-Stokes Cheyne-Stokes respirations is breathing pattern of deep to shallow breaths followed by periods of apnea. Can be result of drug overdose, or increased ICP, and can precede death.

A nurse is assessing a client who is unconscious. The client has 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? B. Cheyne-Stokes

C. Retinal Detachment

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 client might have which of the following disorders? C. Retinal detachment

A. Widened pulse pressure A widening of the pulse pressure is a manifestation of increased ICP. Other manifestations include pupil change, change in LOC, nausea and vomiting.

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? A. Widened pulse pressure

C. Level of consciousness ABCs. A change in the client's LOC can be first indication of a change in neurological status.

A nurse is assessing a client who was admitted to the family 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 clients neurological status? C. LOC

A. The client's serum osmolarity is 310mOsm/L 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 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? A. The client's serum osmolarity is 310 mOsm/L.

B. Cochlea Meniere's disease is a condition of the inner ear in which excess fluid distorts the inner ear canal system. This distortion decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system.

A nurse is caring for a client who has Meniere's disease. The nurse should identify that Meniere's disease affects which structure of the ear? B. Cochlea

B. Respiratory effort The nurse should monitor the respiratory effort of a client who has an injury to the brainstem. The medulla in the brainstem controls the respiratory center.

A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? B. Respiratory effort

C. Rigid skull containing cranial contents 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 caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). This increase in ICP is due to which of the following? C. Rigid skull containing cranial contents

D. Right-sided hemiplegia 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 left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? D. Right-sided hemiplegia

A. The client rigidly extends his arms. The 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 has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? A. The client rigidly extends his arms

D. Redirect the client to a different activity with a small group of people. The nurse should redirect the client to another activity to distract 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 dementia and is experiencing anxiety. Which of the following actions should the nurse take? D. Redirect the client to a different activity with a small group of people.

B. Monitor vitals every 2 hours C. Assess neurological status every 4 hours E. Keep the client's room darkened

A nurse is caring for a client who has encephalitis due to West Nile Virus. Which of the following actions should the nurse take? (Select all that apply) B. Monitor vitals every 2 hour C. Assess for neurological status every 4 hours. E. Keep the client's room darkened.

C. Frontal The nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thoughts.

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?

D. Eustachian tube 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 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? D. Eustachian tube

A. Add gestures when speaking with the client. The nurse should use gestures when speaking with the client to increase the client's understanding of the conversation.

A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? A. Add gestures when speaking with the client

C. The client is unable to understand words or sentences she hears. Clients who cannot understand words or sentences they hear have receptive aphasia.

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? C. The client is unable to understand words or sentences she hears.

B. Place the client in a high-Fowler's position According to evidence-based practice the nurse should place the client in high-Fowler's position to decrease the client's blood pressure and reduce risk of end-organ damage from sudden rise in BP.

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? B. Place the client in a high-Fowler's position

A. The client's ability to clear oral secretions. ABCs

A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? A. The client's ability to clear oral secretions.

A. Dysphagia Dysphagia can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement? A. Dysphagia

D. Monitor the client for increased ICP. The greatest risk to this client is an injury from increased ICP which can result in decreased cerebral perfusion and neurological injury.

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? D. Monitor the client for increased ICP

B Blood Pressure The most common causes of a TIA are atherosclerotic plaque in the carotid arteries and hypertension.

A nurse is preparing an older adult client who had a transient attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters at home? B. Blood Pressure

A. Reduce dietary sodium. Limited sodium intake can help control hypertension and prevent future TIAs.

A nurse is providing discharge teaching to a client who has had a transient attack (TIA). Which of the following instructions should the nurse include? A. Reduce dietary sodium

B. Protect the client's head. This client is at greatest risk for injury from hitting his head.

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? B. Protect the client's head

A. Dysphagia ABCs.

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? A. Dysphagia

C. Thoroughly shampoo hair prior to EEG. The nurse should instruct the client to thoroughly wash her hair prior to the EEG because hairspray, oils, and other hair preparations interfere with recording results of the EEG.

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? C. Thoroughly shampoo hair prior to EEG

C. Avoid sudden movements Meniere'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 increase manifestations.

A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching? C. Avoid sudden movements

C. Acute episodes are usually followed by remissions, which can vary in duration.

A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual cause of MS. Which of the following responses should the nurse make? C. Acute episodes are usually followed by remissions, which can vary in duration.

D. Limit choices offered to the client. Choices should be limited for a client who has stage II AD to reduce confusion and frustration.

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? D. Limit choices offered to the client.

D. Reading the newspaper With presbyopia, the lens is unable to change shape to focus on new objects. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens.

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? D. Reading the newspaper

D. The client has a pacemaker

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. Which of the following pieces of information in the client's history is a contraindication to this procedure? D. The client has a pacemaker

D. Sclerosis of the ossicles 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 nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following pieces in the client's medical record should the nurse identify as a risk factor for tinnitus? D. Sclerosis of the ossicles

A. You'll have to lie very still on a long, narrow table during the test. Nurse should inform the client that the test will require the client to lay still on a long, narrow table. Movement during the test interferes with the quality of the films.

A nurse is teaching a client about computed tomography (CT) scanning of the brain. Which of the following teaching points should the nurse include? A. You'll have to lie very still on a long, narrow table during the test.

D. Driving can be dangerous due to the loss of peripheral vision E. Laser surgery can help reestablish the flow of aqueous humor. Damage to the optic nerve that occurs secondary to increased ICP 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 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? (Select all that apply) D. Driving can be dangerous due to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of aqueous humor.

D. Dry Eyes 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 teaching a client who has myopia about laser-assisted in situ karatomileusis (LASIK) surgery. Which of the following is an adverse effect of LASIK surgery? D. Dry eyes

Black Tag 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 ICP. In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible.

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? Black Tag

B. Turn off sources of oxygen near the fire

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? B. Turn off sources of oxygen near the fire.

C. Check airway patency ABCs

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? C. Check airway patency

C. Provide supplemental oxygen ABCs

An emergency room nurse is assessing a client who has a new traumatic brain injury. 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? C. Provide supplemental oxygen

A. Remote The nurse tests remote or long-term memory by asking questions such as where and when the client was born etc.

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 teaching? A. Remote