care of the patient with a neurological disorder

d)

a 73-year-old patient has been diagnosed with ischemic stroke following diagnostic studies. which medication must be given within a 4.5-hour window of symptom onset to be effective in lysing a clot? a) heparin b) coumadin c) plavix d) alteplase

d)

a client who has GB asks, "will i ever get better?" which response would be the most appropriate answer by the nurse? a) "you'll notice your strength will improve each day." b) "we are doing everything we can to provide the best care." c) "you seem concerned about getting better. what do you think?" d) "your chances for recovery are very good, but recovery is slow."

1) 2) 3) 4) the nurse would plan seizure precautions for a client with a seizure disorder. the precautions include padded side rail and an airway, and oxygen and suction equipment at the bedside. attempts to force a padded tongue blade between clenched teeth may result in injury to the teeth and mouth; therefore, a padded tongue blade is not placed at the bedside.

a client with a seizure disorder is being admitted to the hospital. which would the nurse plan to implement for this client? select all that apply. 1) pad the bed's side rails. 2) place an airway at the bedside. 3) place oxygen equipment at the bedside. 4) place suction equipment at the bedside. 5) tape a padded tongue blade to the wall at the head of the bed.

c) the nurse should recommend the meningococcal vaccine for adolescents prior to starting college due to the increased risk for infection in communal living facilities.

a health department nurse is reviewing the use of the meningococcal vaccine for the prevention of meningitis with a newly licensed nurse. which of the following information should the nurse include? a) the vaccine reduces the risk of respiratory infection. b) administer this vaccine in a series of four doses. c) recommend this vaccine for adolescents before starting college. d) the vaccine series begins at 2 months of age.

c) when using the airway, breathing, and circulation approach to client care, the priority data to monitor is oxygen saturation. brain tissue can only survive for 3 min before permanent damage occurs.

a nurse is assisting with the care of a client following surgical evacuation of a subdural hematoma. which of the following data is the priority to monitor? a) glasgow coma scale b) cranial nerve function c) oxygen saturation d) pupillary response

c) benign brain tumors develop from the meninges or cranial nerves and do not metastasize.

a nurse is caring for a client who has a benign brain tumor. the client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. which of the following is an appropriate response by the nurse? a) "it can spread to breasts and kidneys." b) "it can develop in your gastrointestinal tract." c) "it is limited to brain tissue." d) "it probably started in another area of your body and spread to your brain."

a) a client who has experienced a right-hemispheric stroke can exhibit impulse control difficulty, such as the urgency to use the restroom. b) a client who has experienced a right-hemispheric stroke can exhibit left-sided hemiplegia. c) a client who has experienced a right-hemispheric stroke can experience a loss in depth perception. e) a client who has experienced a right-hemispheric stroke can demonstrate a lack of awareness of surroundings.

a nurse is caring for a client who has experienced a right-hemispheric stroke. which of the following findings should the nurse expect? (select all that apply.) a) impulse control difficulty b) left hemiplegia c) loss of depth perception d) aphasia e) lack of situational awareness

b) the client is unable to visualize to the left midline of her body. placing the bedside table on the right side of the client's bed will permit visualization of items on the table.

a nurse is caring for a client who has left homonymous hemianopsia. which of the following interventions should the nurse implement? a) instruct t he client to scan to the right to see objects on the right side of her body. b) place the bedside table on the right side of the bed. c) orient the client to the food on her plate using the clock method. d) place the wheelchair on the client's left side.

b) loss of cognitive function is a manifestation associated with MS.

a nurse is caring for a client who has multiple sclerosis. which of the following findings should the nurse expect? a) fluctuations in blood pressure b) loss of cognitive function c) ineffective cough d) drooping eye lids

b) decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP. d) the nurse should administer a stool softener to decrease the need to bear down during bowel movements, which can increase ICP.

a nurse is caring for a client who is at risk for increased intracranial pressure. which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (select all that apply.) a) suction the client frequently. b) decrease the noise level in the client's room. c) elevate the client's head on two pillows. d) administer a stool softener. e) keep the client well hydrated.

a) the greatest risk to the client is aspiration during the postictal phase. therefore, the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth keeping the airway patent.

a nurse is caring for a client who just experienced a generalized seizure. which of the following actions should the nurse perform first? a) keep the client in a side-lying position. b) document the duration of the seizure. c) reorient the client to the environment. d) provide client hygiene.

a) the nurse should place the client in supine position when checking for brudzinski's sign. c) the nurse should place her hands behind the client's neck when checking for brudzinski's sign, in order to flex the client's neck. d) the nurse should bend the client's head toward the chest when checking for brudzinski's sign.

a nurse is checking for the presence of brudzinski's sign in a client who has suspected meningitis. which of the following actions should the nurse take? (select all that apply.) a) place the client in supine position. b) flex client's hip and knee. c) place hands behind the client's neck. d) bend client's head toward chest. e) straighten the client's flexed leg at the knee.

a) areas of loss of skin sensation are a finding in a client who has MS. b) nystagmus is a finding in a client who has MS. e) ataxia occurs in the client who has MS as muscle weakness develops and there is loss of coordination.

a nurse is collecting data from a client who has a new diagnosis of multiple sclerosis. which of the following findings should the nurse expect? (select all that apply.) a) areas of paresthesia b) involuntary eye movements c) alopecia d) increased salivation e) ataxia

a) overwhelming fatigue can trigger a seizure by stimulating abnormal electrical neuron activity. b) caffeinated products from the diet can trigger a seizure by stimulating abnormal electrical neuron activity. c) flashing lights can trigger a seizure by stimulating abnormal electrical neuron activity.

a nurse is reinforcing education about trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. which of the following information should the nurse include in this review? (select all that apply.) a) avoid overwhelming fatigue. b) remove caffeinated products from the diet. c) limit looking at flashing lights. d) perform aerobic exercise. e) limit episodes of hypoventilation. f) use of aerosol hairspray is recommended.

a) the nurse should implement privacy to minimize the client's embarrassment. b) the nurse should ease the client to the floor to prevent falling and injury. c) the nurse should move the furniture away from the client to prevent injury. d) the nurse should loosen the client's clothing to minimize restriction of movement. e) the nurse should protect the client's head from injury by placing the client's head in her lap or using a pillow or blanket under the head during a seizure.

a nurse is collecting data from a client who has a seizure disorder. the client reports sensing an aura and is about to have a seizure. which of the following actions should the nurse implement? (select all that apply.) a) provide privacy. b) ease the client to the floor if standing. c) move furniture away from the client. d) loosen the client's clothing. e) protect the client's head with padding. f) restrain the client.

a) changes in level of consciousness are an early indicator of increased ICP. b) increased ICP can cause behavior changes, such as restlessness and irritability. c) unequal pupils indicates pressure on the oculomotor nerve secondary to increased ICP. e) a headache is a manifestation of increased ICP.

a nurse is collecting data from a client who has increased intracranial pressure. which of the following findings should the nurse expect? (select all that apply.) a) disoriented to time and place b) restlessness and irritability c) unequal pupils d) ICP 15 mm Hg e) headache

b) the client is exhibiting manifestations of possible meningitis. when using the urgent vs. nonurgent approach to care, the nurse determines the priority action is to initiate droplet precautions to prevent spread of the disease to others.

a nurse is collecting data from a client who reports severe headache and stiff neck. data collection reveals positive kernig's and brudzinski's signs. which of the following actions should the nurse perform first? a) administer antibiotics. b) implement droplet precautions. c) obtain IV access. d) decrease bright lights.

c) a client who experienced a left-hemispheric stroke can demonstrate depression and frustration regarding physical limitations due to the stroke.

a nurse is collecting data on a client who has experienced a left-hemispheric stroke. which of the following manifestations should the nurse expect? a) impulse control difficulty b) poor judgment c) frustrated about deficits d) loss of depth perception

b) the nurse should provide an emesis basin at the bedside, because the client who has meningitis can have nausea and vomiting. c) the nurse should plan to administer antipyretic medication for fever to a client who has meningitis. d) the nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meningococcal meningitis.

a nurse is contributing to the plan of care for a client who has bacterial meningitis. which of the following interventions should the nurse include? (select all that apply.) a) monitor for hypotension. b) provide an emesis basin at the bedside. c) administer antipyretic medication. d) perform a skin assessment. e) keep the head of the bed flat.

a) suction equipment should be available in case of choking and aspiration. b) the client should be given liquids that are thicker than water to prevent aspiration. c) placing food on the unaffected side of the client's mouth will allow her to have better control of the food and reduce the risk of aspiration. e) the client should be taught to flex her neck, tucking the chin down and under to close the epiglottis during swallowing.

a nurse is contributing to the plan of care for a client who has dysphagia and a new dietary prescription. which of the following interventions should the nurse include in the plan? (select all that apply.) a) have suction equipment available for use. b) feed the client thickened liquids. c) place food on the unaffected side of the client's mouth. d) assign an assistive personnel to feed the client slowly. e) instruct the client to swallow with her neck flexed.

a) clients who have global aphasia have difficulty with speaking and understanding speech. one strategy that can enhance client understanding is speaking to the client at a slower rate. b) one strategy that can enhance understanding is the use of alternative forms of communication, such as flash cards with pictures or a computer. e) one strategy that can enhance understanding is giving instructions one step at a time.

a nurse is contributing to the plan of care for a client who has global aphasia. which of the following interventions should the nurse include in the client's plan? (select all that apply.) a) speak to the client at a slower rate. b) assist the client to use flash cards with pictures. c) speak to the client in a loud voice. d) complete sentences that the client cannot finish. e) give instructions one step at a time.

a) the client is at risk for seizures due to possible increased ICP. therefore, the nurse should implement seizure precautions to reduce the client's risk for injury. d) the nurse should turn off room lights and the television, because they can increase neuron stimulation and cause a seizure when a client is at risk for increased ICP. e) the nurse should monitor for impaired extraocular movements because this finding can indicate increased ICP.

a nurse is contributing to the plan of care for a client who has meningitis and it at risk for increased intracranial pressure. which of the following interventions should the nurse recommend? (select all that apply.) a) implement seizure precautions. b) perform neurological checks four times a day. c) administer morphine for the report of neck and generalized pain. d) turn off room lights and television. e) monitor for impaired extraocular movements. f) encourage the client to cough frequently.

c) the client should take phenytoin at the same time every day to enhance effectiveness.

a nurse is reinforcing discharge instructions with a female client who has a prescription for phenytoin. which of the following information should the nurse include? a) consider taking oral contraceptives when on this medication. b) watch for receding gums when taking the medication. c) take the medication at the same time every day. d) provide a urine sample to determine therapeutic levels of the medication.

c) the client should expect to have a temporary voice change due to stimulation of the device on the vagal nerve.

a nurse is reinforcing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. which of the following statements should the nurse include? a) "i will have a sore throat after placement of the stimulator." b) "this stimulator will stop my tonic/clonic seizures." c) "i can expect to have a temporary voice change." d) "the device is inserted under local anesthesia."

d) dantrolene and tizanidine are antispasmodic medications that are given to clients who have MS to treat muscle spasms. an adverse effect of this medication is a yellow appearance of the skin, also known as jaundice. the nurse should instruct the client to monitor for this finding, as this can indicate impaired liver function.

a nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. which of the following statements should the nurse include in the teaching? a) "this medication will help you with your tremors." b) "this medication will help you with your bladder function." c) "this medication may cause your skin to bruise easily." d) "this medication may cause your skin to appear yellow in color."

a) dexamethasone is a common steroid prescribed to reduce cerebral edema. c) weight gain is an adverse effect of dexamethasone. e) fluid retention is an adverse effect of dexamethasone.

a nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. which of the following are appropriate statements by the nurse? (select all that apply.) a) "it is given to reduce swelling of the brain." b) "you will need to monitor for low blood sugar." c) "you may notice weight gain." d) "tumor growth will be delayed." e) "it can cause you to retain fluids."

d) a positive romberg sign is indicated when a client loses his balance while attempting to stand erect with his eyes closed.

a nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive romberg sign. which of the following actions should the nurse take to check for this manifestation? a) stroke the lateral aspect of the sole of the foot. b) ask the client to blink his eyes. c) observe for facial drooping. d) have the client stand erect with eyes closed.

c)

a patient diagnosed with a stroke is experiencing slurred speech. the nurse would accurately document this finding as which clinical manifestation of stroke? a) aphasia b) dysphasia c) dysarthria d) apraxia

d)

a patient is admitted with a closed head injury that was sustained in a motorcycle accident. the patient has been showing an upward trend in ICP measurements. what is the first priority action that the nurse should take with this patient? a) administer 100 mg of IV phenobarbital as as ordered b) increase the ventilator settings to a respiratory rate of 20 breaths/min c) administer 20 g of IV mannitol as ordered d) reposition the patient to avoid neck flexion

d)

a patient is scheduled for an EEG tomorrow. which piece of information should the nurse provide to the patient prior to the procedure? a) antiseizure medications need to be taken prior to procedure. b) sedation will be given during the procedure. c) there is a slight chance of electric shock. d) maintain a sleep-deprived state the night before the procedure.

a)

a patient is undergoing a cerebral angiography to rule out an aneurysm. when preparing the patient for the procedure, what would the nurse include in the instructions? a) expect a metallic taste when the contrast agent is injected. b) you will need a full bladder prior to the procedure. c) maintain an NPO status. d) general sedation will be given prior to the procedure.

c)

a patient sustained a C6 SCI 4 hours a go. what nursing diagnosis is a priority? a) urinary retention b) risk for impaired skin integrity c) ineffective breathing pattern d) powerlessness

b)

a patient with parkinson disease is seen in the neurology clinic for treatment. the nurse identifies this disorder as being caused by a lack of which neurotransmitters? a) acetylcholine b) dopamine c) serotonin d) gamma-aminobutyric acid

4) dyskinesia and impaired voluntary movement may occur with high levodopa dosages. nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.

carbidopa-levodopa is prescribed for a client with parkinson's disease, and the nurse monitors the client for adverse effects of the medication. which sign/symptom indicates the client is experiencing an adverse effect? 1) pruritus 2) tachycardia 3) hypertension 4) impaired voluntary movements

1) ibuprofen is a nonsteroidal anti-inflammatory drug. NSAIDs would be given with milk or food to prevent gastrointestinal irritation. options 2, 3, and 4 are incorrect.

ibuprofen is prescribed for a client. which instruction would the nurse give the client about taking this medication? 1) take with 8 oz of milk. 2) take in the morning after arising. 3) take 60 minutes before breakfast. 4) take at bedtime on an empty stomach.

1) phenytoin is an antiseizure medication. gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication. the client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits. the client would not skip medication doses because this could precipitate a seizure. capsules should not be chewed or broken. the client needs to be instructed to report a sore throat, fever, glandular swelling, or any skin reaction because this indicates hematological toxicity.

phenytoin, 100 mg orally three times daily, has been prescribed for a client for seizure control. the nurse reinforces instructions regarding the medication to the client. which statement by the client indicates an understanding of the instructions? 1) "i will use a soft toothbrush to brush my teeth." 2) "it's all right to break the capsules to make it easier for me to swallow them." 3) "if i forget to take my medication, i can wait until the next dose and eliminate that dose." 4) "if my throat becomes sore, it's a normal effect of the medication and it's nothing to be concerned about."

4) leakage of CSF from the ears or nose may accompany basilar skull fracture. it can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, which is known as the halo sign. it also tests positive for glucose. options 1, 2, and 3 are not characteristics of CSF.

the client has clear fluid leaking from the nose after a basilar skull fracture. the nurse determines that this is cerebrospinal fluid if the fluid meets which criteria? 1) it is grossly bloody in appearance and has a pH of 6 2) it clumps together on the dressing and has a pH of 7 3) it is clear in appearance and tests negative for glucose 4) it separates into concentric rings and tests positive for glucose

4) after CT scanning, the client may resume all usual activities. the client would be encouraged to take in extra fluids to replace those lost with diuresis from the contrast dye. options 1, 2, and 3 are unnecessary.

the client has just undergone a computed tomography scan with a contrast medium. which statement by the client demonstrates an understanding of postprocedure care? 1) "i need to eat lightly for the remainder of the day." 2) "i need to rest quietly for the remainder of the day." 3) "i need to wait to take any medication for at least 4 hours." 4) "i need to drink extra fluids for the remainder of the day."

4) there is a significant association between cervical spine injury and head injury. for this reason, the nurse leaves any form of spinal immobilization in place until lateral cervical spine x-rays rule out fracture or other damage and the results have been reviewed by the PHCP.

the client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. the nurse expects that the cervical collar will remain in place until which time? 1) the client is taken for spinal x-rays. 2) the family comes to visit after surgery. 3) the nurse needs to provide physical care. 4) the primary health care provider reviews the x-ray results.

4) the client undergoing a lumbar puncture is positioned lying on the side, with knees bent, drawn up to the abdomen, and the chin tucked into the chest. this position helps to open the spaces between the vertebrae.

the client is having a lumbar puncture performed. the nurse would place the client in which position for the procedure? 1) supine, in semi-fowler's 2) prone, in slight trendelenburg 3) prone, with a pillow under the abdomen 4) side-lying, with legs pulled up and chin to the chest

2) 3) 4) meperidine hydrochloride is an opioid analgesic. side and adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.

the client is receiving meperidine hydrochloride for pain. which signs/symptoms are side and adverse effects of this medication? select all that apply. 1) diarrhea 2) tremors 3) drowsiness 4) hypotension 5) urinary frequency 6) increased respiratory rate

2) the therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL. therefore, options 1, 3, and 4 are incorrect.

the client is taking phenytoin for seizure control, and a blood sample for a serum drug level is drawn. which laboratory finding indicates a therapeutic serum drug result? 1) 5 mcg/mL 2) 15 mcg/mL 3) 25 mcg/mL 4) 30 mcg/mL

4) activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of the ICP. some of these activities include isometric exercises, valsalva maneuver, coughing, sneezing, and blowing the nose. exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

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 activity? 1) blowing the nose 2) isometric exercises 3) coughing vigorously 4) exhaling during positioning

2) a concussion after head injury is a temporary loss of consciousness without evidence of structural damage. after concussion, the family is taught to monitor the client and call the primary health care provider or return the client to the emergency department if certain signs/ symptoms are noted. these include confusion, difficulty awakening or speaking, one-sided weakness, vomiting, or severe headache. minor headache is expected.

the client was seen and treated in the emergency department for a concussion. before discharge, the nurse explains the signs/symptoms of a worsening condition. the nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? 1) vomiting 2) minor headache 3) difficulty speaking 4) difficulty awakening

4) crutchfield tongs are applied after drilling holes in the client's skull under local anesthesia. weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. the nurse ensures that weights hang freely and that the amount of weight matches the current prescription. the client with crutchfield tongs is placed on a stryker frame or roto-rest bed. the nurse does not remove the weights to administer care or change the level of tension or traction based on client comfort level.

the client with a cervical spine injury has crutchfield tongs applied in the emergency department. the nurse would perform which essential action when caring for this client? 1) provide a standard bed frame 2) remove the weights to reposition the client 3) remove the weights if the client is uncomfortable 4) compare the amount of prescribed weights with the amount in use

3) the antidote for cholinergic crisis is atropine sulfate. acetylcysteine is the antidote for acetaminophen. vitamin K is the antidote for warfarin, and protamine sulfate is the antidote for heparin.

the client with myasthenia gravis is receiving pyridostigmine. the nurse monitors for signs/symptoms of cholinergic crisis caused by overdose of the medication. the nurse checks the medicine supply to ensure that which medication is available for administration if a cholinergic crisis occurs? 1) vitamin K 2) acetylcysteine 3) atropine sulfate 4) protamine sulfate

4) cholinergic crisis occurs as a result of an overdose of medication. indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.

the client with myasthenia gravis is suspected of having cholinergic crisis. which sign/symptom indicates this crisis is taking place? 1) ataxia 2) mouth sores 3) hypothermia 4) hypertension

4) the most frequent cause of autonomic dysreflexia is a distended bladder. straight catheterization would be performed every 4 to 6 hours, and indwelling bladder catheters would be checked frequently for kinks in the tubing. it is not appropriate to catheterize the client every 12 hours. constipation and fecal impaction are other causes, so maintaining bowel regularity is important. other causes include stimulation of the skin from tactile, thermal, or painful stimuli. the nurse administers care to minimize risk in these areas.

the client with spinal cord injury is prone to experiencing autonomic dysreflexia. the least appropriate measure to minimize to risk of autonomic dysreflexia is which action? 1) strictly adhering to a bowel retraining program 2) keeping the linen wrinkle-free under the client 3) avoiding unnecessary pressure on the lower limbs 4) limiting bladder catheterization to once every 12 hours

1) key nursing actions are to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. the nurse can also clearly label the client's chart identifying the risk for autonomic dysreflexia. client and family would be taught to recognize, and later manage, the signs/symptoms of this syndrome.

the client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. after checking vital signs, which immediate action would the nurse take? 1) raise the head of the bed and remove the noxious stimulus 2) lower the head of the bed and remove the noxious stimulus 3) lower the head of the bed and administer an antihypertensive agent 4) remove the noxious stimulus and administer an antihypertensive agent

3) adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbance, thrombophlebitis, dysrhythmia, and dermatological effects. options 1, 2, and 4 identify normal laboratory values.

the client with trigeminal neuralgia is being treated with carbamazepine. which laboratory result indicates that the client is experiencing an adverse effect of the medication? 1) sodium level, 140 mEq/L 2) uric acid level, 5.0 mg/dL 3) white blood cell count, 3000 mm3 4) blood urea nitrogen level, 15 mg/dL

a) c) e)

the nurse assesses the LOC of a patient who suffered a head injury and determines that the patient's GCS score is 15. which of the following responses did the nurse assess to determine the GCS score? select all that apply. a) spontaneous eye opening b) tachycardia, hypotension, bradycardia c) ability to follow commands d) unequal pupil size e) oriented to person, place, and time

2) driving is not allowed because the device impairs the range of vision. the halo device alters balance and can cause fatigue because of its weight. the client would cleanse the skin daily under the vest or the device to protect the skin from ulceration and would use powder or lotions sparingly or not at all. the wool liner would be changed if odor becomes a problem. the client needs to have food cut into small pieces to facilitate chewing and use a straw for drinking. pin care is done as instructed.

the nurse has provided discharge instructions to a client with an application of a halo device. the nurse determines that the client needs further teaching if which statement is made? 1) "i will use a straw for drinking." 2) "i will drive only during the daytime." 3) "i will use caution because the device alters balance." 4) "i will wash my skin daily under the lamb's wool liner of the vest."

a)

the nurse is assisting with a lumbar puncture. what is the most common complication for which the nurse should monitor the patient following the procedure? a) post-lumbar puncture headache b) herniation of intracranial contents c) spinal epidural abscess d) meningitis

3) following supratentorial surgery, the head of the bed is kept at a 30- to 45-degree angle. the head and neck would not not be angled either anteriorly or laterally, but rather would be kept in a neutral position. this will promote venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

the nurse is caring for a client who has undergone craniotomy with a supratentorial incision. the nurse would plan to place the client in which position postoperatively? 1) head of bed flat, head and neck midline 2) head of bed flat, head turned to the nonoperative side 3) head of bed elevated 30 to 45 degrees, head and neck midline 4) head of bed elevated 30 to 45 degrees, head turned to the operative side

3) phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. options 1, 2, and 4 are not accurate.

the nurse is caring for a client who is taking phenytoin for control of seizures. during data collection, the nurse notes that the client is taking birth control pills. which information would the nurse provide to the client? 1) pregnancy would be avoided while taking phenytoin. 2) the client may stop taking the phenytoin if it is causing severe gastrointestinal effects. 3) the potential for decreased effectiveness of the birth control pills exists while taking phenytoin. 4) the increased risk of thrombophlebitis exists while taking phenytoin and birth control pills together.

4) a change in vital signs may be a late sign of increased ICP. trends include increasing temperature and blood pressure and decreasing pulse and respirations. respiratory irregularities may also arise.

the nurse is caring for a client with increased intracranial pressure. which change in vital signs would occur if ICP is rising? 1) increasing temperature, increasing pulse, increasing respirations, decreasing BP 2) decreasing temperature, decreasing pulse, increasing respirations, decreasing BP 3) decreasing temperature, increasing pulse, decreasing respirations, increasing BP 4) increasing temperature, decreasing pulse, decreasing respirations, increasing BP

3) the client with spinal cord injury above level T7 is at risk for autonomic dysreflexia. it is characterized by a severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. other signs include nasal stuffiness, blurred vision, nausea, and sweating. it is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

the nurse is caring for the client who has suffered spinal cord injury. the nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? 1) sudden tachycardia 2) pallor of the face and neck 3) severe, throbbing headache 4) severe and sudden hypotension

b)

the nurse is testing the cranial nerves of a patient diagnosed with myasthenia gravis. the nurse asks the patient to clench his jaw while she palpates the temporal and masseter muscles. the nurse is correctly testing which cranial nerve? a) abducens b) trigeminal c) acoustic d) hypoglossal

a) b) d)

the nurse knows that the signs and symptoms of meningeal irritation include which of the following? select all that apply. a) nuchal rigidity and headache b) kernig and brudzinski signs c) aphasia and motor weakness d) photophobia e) ptosis

b)

the nurse notices clear fluid draining from the nose of a patient who sustained a head injury 2 hours ago. this may indicate the presence of what condition? a) cerebral concussion b) basal skull fracture c) brain tumor d) sinus infection

2) the head of the client with increased ICP would be positioned so that the head is in a neutral, midline position. the nurse would avoid flexing or extending the neck and avoid turning the head side to side. the head of the bed needs to be raised to 30 to 45 degrees. use of proper positions promotes venous drainage from the cranium to keep ICP down.

the nurse observed the assistive personnel positioning the client with increased intracranial pressure. which observation would require intervention by the nurse? 1) the client's head is placed midline 2) the client's head is turned to the side 3) the client's neck is in neutral position 4) the client's head of the bed is elevated 30 to 45 degrees

d)

what is the most common initial symptom that a nurse might expect a client with MS to complain about? a) diarrhea b) headaches c) skin infections d) visual disturbances

d)

what manifestations will the nurse observe in the patient undergoing a tonic-clonic seizure? a) jerking in one extremity that spreads gradually to adjacent areas b) vacant staring and abrupt cassation of all activity c) facial grimaces, patting motions, and lip smacking d) loss of consciousness, body stiffening, and violent muscle contractions

d) e)

which interventions should the nurse's plan of care include to help prevent autonomic dysreflexia in a patient with SCI? select all that apply. a) check for fecal impactions. b) monitor blood pressure for hypotension. c) check the urinary drainage system for any obstruction. d) monitor bowel movements. e) instruct the patient to wear a medic alert bracelet.

d)

while assessing a client with parkinson disease, the nurse identifies bradykinesia when the client exhibits which symptom? a) muscle flaccidity b) an intention tremor c) paralysis of the limbs d) slow spontaneous movement