Med surg 2 test practice questions (exam 1, neuro)

The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A. Position the client in a high-Fowler position when in bed. B. Support the knees with a pillow when the client is in bed. C. Perform passive ROM exercises as prescribed. D. Administer NSAIDs as prescribed.

Perform passive ROM exercises as prescribed

A client with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this client? A. Cerebral angiography B. ABG analysis C. CT D. EEG

EEG

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A. Generalized seizure B. Absence seizure C. Focal seizure D. Unclassified seizure

Absence seizure

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the health care provider immediately.

Call the health care provider immediately

A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching? A. Care of the cervical collar B. Technique for performing neck ROM exercises C. Home assessment of ABGs D. Techniques for restoring nerve function

Care of the cervical collar

The ED is notified that a 6-year-old child is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? A. Promoting adequate circulation B. Treating the child's increased ICP C. Assessing secondary brain injury D. Preserving brain homeostasis

Preserving brain homeostasis

An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiologic factors? Select all that apply. A. "Are you exposed to any toxins or chemicals at work?" B. "How would you describe your ability to cope with stress?" C. "What medications are you currently taking?" D. "When was the last time you were hospitalized?" E. "Does anyone else in your family struggle with headaches?"

"Are you exposed to any toxins or chemicals at work?" "How would you describe your ability to cope with stress?" "What medications are you currently taking?" "Does anyone else in your family struggle with headaches?"

A nurse is performing a complex neurological assessment on a client recently diagnosed with Alzheimer disease. What question should the nurse anticipate to ask when assessing the client's language ability? A. "How are a pencil and pen alike?" B. "Can you write your name on this blank sheet of paper?" C. "Can you tell me what year it is?" D. "What is the name of the president of the United States?"

"Can you write your name on this blank sheet of paper?"

The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis? A. "Client exhibits increased muscle tone." B. "Client demonstrates normal muscle structure with no evidence of atrophy." C. "Client demonstrates hyperactive deep tendon reflexes." D. "Client demonstrates an absence of deep tendon reflexes."

"Client demonstrates an absence of deep tendon reflexes."

The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response? A. "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." B. "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." C. "I know you understand that nerve cells do not remyelinate, so the health care provider is the best one to answer your question." D. "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."

"Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."

An older adult has encouraged the spouse husband to visit their primary provider, stating that concern that spouse may have Parkinson disease. Which description of the spouse's health and function is most suggestive of Parkinson disease? A. "Lately he seems to move far more slowly than he ever has in the past." B. "He often complains that his joints are terribly stiff when he wakes up in the morning." C. "He's forgotten the names of some people that we've known for years." D. "He's losing weight even though he has a ravenous appetite."

"Lately he seems to move far more slowly than he ever has in the past."

A client with Parkinson disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The client reports achieving relief for the past few weeks by using over-the-counter laxatives. How should the nurse respond? A. "It's important to drink plenty of fluids while you're taking laxatives." B. "Make sure that you supplement your laxatives with a nutritious diet." C. "Let's explore other options, because laxatives can have side effects and create dependency." D. "You should ideally be using herbal remedies rather than medications to promote bowel function."

"Let's explore other options, because laxatives can have side effects and create dependency."

A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test? A. "No metal objects can enter the procedure room." B. "You need to fast for 8 hours prior to the test." C. "You will need to lie still throughout the procedure." D. "There will be a lot of noise during the test."

"You will need to lie still throughout the procedure."

The nurse is caring for a client newly diagnosed with a primary brain tumor. The client asks the nurse where the tumor came from. What would be the nurse's best response? A. "Your tumor originated from somewhere outside the CNS." B. "Your tumor likely started out in one of your glands." C. "Your tumor originated from cells within your brain itself." D. "Your tumor is from nerve tissue somewhere in your body."

"Your tumor originated from cells within your brain itself."

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps. Place the steps in the order in which they occur. All options must be used. 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated A. 635241 B. 352416 C. 236145 D. 162534

236145

The nurse is preparing to provide care for a client diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what issue? A. Genetic dysfunction B. Upper and lower motor neuron lesions C. Decreased conduction of impulses in an upper motor neuron lesion D. A lower motor neuron lesion

A lower motor neuron lesion

An older adult client is being discharged home. The client lives alone and has atrophy of the olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home? A. Grab bars B. Nonslip mats C. Baseboard heaters D. A smoke detector

A smoke detector

Paramedics have brought an intubated client to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? A. Keep the head of the bed (HOB) flat at all times. B. Teach the client to perform the Valsalva maneuver. C. Administer benzodiazepines on a PRN basis. D. Perform endotracheal suctioning every hour.

Administer benzodiazepines on a PRN basis

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client? A. Antiemetic medications on day three of injury B. Aspiration precautions on day four of injury C. Intubation and ventilator support on day one of injury D. Anticonvulsant medications on day two of injury

Anticonvulsant medications on day two of injury

The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping? A. Help the family understand that the client could have died. B. Emphasize the importance of accepting the client's new limitations. C. Have the members of the family plan the client's inclient care. D. Assist the family in setting appropriate short-term goals.

Assist the family in setting appropriate short-term goals

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? A. Ventricular tachycardia B. Atrial fibrillation C. Supraventricular tachycardia D. Bundle branch block

Atrial fibrillation

The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication? A. Impaired skin integrity B. Cognitive deficits C. Hemorrhage D. Autonomic dysfunction

Autonomic dysfunction

The nurse is assessing a client with a spinal cord injury that reports a severe headache with a rapid onset. The nurse knows that this could be a symptom of which complication of a spinal cord injury? A. Autonomic dysreflexia B. Spinal shock C. Retinal hemorrhage D. Myocardial infarction

Autonomic dysreflexia

The nurse is discharging a client home after surgery for trigeminal neuralgia. What advice should the nurse provide to this client in order to reduce the risk of injury? A. Avoid watching television or using a computer for more than 1 hour at a time. B. Use over-the-counter antibiotic eye drops for at least 14 days. C. Avoid rubbing the eye on the affected side of the face. D. Rinse the eye on the affected side with normal saline daily for 1 week.

Avoid rubbing the eye on the affected side of the face

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? A. Respiratory distress and projectile vomiting B. Bradycardia and hypertension C. Tachycardia and agitation D. Third-spacing and hyperthermia

Bradycardia and hypertension

The health care provider has prescribed a somatosensory evoked responses (SERs) test for a client for whom the nurse is caring. The nurse is justified in suspecting that this client may have a history of what type of neurologic disorder? A. Hypothalamic disorder B. Demyelinating disease C. Brainstem deficit D. Diabetic neuropathy

Demyelinating disease

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? A. Solumedrol B. Dextromethorphan C. Dexamethasone D. Furosemide

Dexamethasone

What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A. Cushing syndrome B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Adrenal crisis D. Diabetes insipidus

Diabetes insipidus

The nurse is caring for a client with a brain tumor and is aware that the normal compensation measures to keep ICP (intracranial pressure) within normal limits may no longer be effective. What are the normal compensation measures for the brain? Select all that apply. A. Displacing or shifting cerebral spinal fluid (CSF) B. Decreasing cerebral perfusion C. Increasing the absorption of CSF D. Shifting brain tissue E. Decreasing cerebral blood volume

Displacing or shifting cerebral spinal fluid (CSF) Increasing the absorption of CSF Decreasing cerebral blood volume

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck

Elevation of the head of the bed

A client, brought to the clinic by the client's spouse and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? A. Metastasis B. Risk for stroke C. Emotional and personality changes D. Pathologic bone fractures

Emotional and personality changes

Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. When should the nurse remove and reapply the splints? A. At the client's request B. Each morning and evening C. Every 2 hours D. One hour prior to mobility exercises

Every 2 hours

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months

Evidence of hemorrhagic stroke

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Schedule passive range of motion every other day. B. Keep activity limited, as the client may be overstimulated. C. Have the client perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.

Exercise the affected extremities passively four or five times a day

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting

Facial droop

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? A. Monro-Kellie hypothesis B. Glasgow Coma scale C. Cranial nerve function D. Mental status examination

Glasgow Coma scale

The neurologic nurse is testing the function of a client's cerebellum and basal ganglia. What action will most accurately test these structures? A. Have the client identify the location of a cotton swab on his or her skin with the eyes closed. B. Elicit the client's response to a hypothetical problem. C. Ask the client to close his or her eyes and discern between hot and cold stimuli. D. Guide the client through the performance of rapid, alternating movements.

Guide the client through the performance of rapid, alternating movements.

A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? A. Support the client's full body weight with a waist belt during ambulation. B. Have a colleague follow the client closely with a wheelchair. C. Avoid mobilizing the client in the early morning or late evening. D. Ensure that the client's family members do not participate in mobilization.

Have a colleague follow the client closely with a wheelchair

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I? A. Have the client identify familiar odors with the eyes closed. B. Assess papillary reflex. C. Utilize the Snellen chart. D. Test for air and bone conduction (Rinne test).

Have the client identify familiar odors with the eyes closed

An 82-year-old client is admitted for observation after a fall. Due to the client's age, the nurse knows that the client is at increased risk for what complication of his injury? A. Hematoma B. Skull fracture C. Embolus D. Stroke

Hematoma

The nurse is providing information to a client about neurological disorders associated with genetic defects. The nurse knows which disease is considered an autosomal dominant disorder? A. Duchenne muscular dystrophy B. Parkinson disease C. Huntington disease D. Fragile X syndrome

Huntington disease

The nurse is caring for a client with a brain tumor who is experiencing symptoms due to compression and infiltration of normal tissue. The pathophysiologic changes that result can cause what manifestations? Select all that apply. A. Intracranial hemorrhage B. Infection of cerebrospinal fluid C. Increased ICP D. Focal neurologic signs E. Altered pituitary function

Increased ICP Focal neurologic signs Altered pituitary function

The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? A. Encourage the client to void every hour. B. Order a low-residue diet. C. Provide total assistance with all ADLs. D. Instruct the client on daily muscle stretching.

Instruct the client on daily muscle stretching

A 37-year-old client is brought to the clinic by the spouse because the client is experiencing loss of motor function and sensation. The health care provider suspects the client has a spinal cord tumor and hospitalizes the client for diagnostic testing. In light of the need to rule out spinal cord compression from a tumor, the nurse will most likely prepare the client for what test? A. Anterior-posterior x-ray B. Ultrasound C. Lumbar puncture D. MRI

MRI

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.

Maintain and improve cerebral tissue perfusion

A 73-year-old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client? A. Older adults are often vague historians. B. Older adults have fewer peripheral nerves than younger adults. C. Many older adults are hesitant to admit that their body is changing. D. Many symptoms can be the result of normal aging process.

Many symptoms can be the result of normal aging process

The nurse is caring for a boy who has muscular dystrophy. When planning assistance with the client's ADLs, what goal should the nurse prioritize? A. Promoting the client's recovery from the disease B. Maximizing the client's level of function C. Ensuring the client's adherence to treatment D. Fostering the family's participation in care

Maximizing the client's level of function

A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A. Encephalitis B. Cerebral spinal fluid leak C. Meningitis D. Catheter occlusion

Meningitis

An ED nurse has just received a call from EMS that they are transporting a 17-year-old client who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what event? A. Syncope (fainting) B. Suicide attempts C. Workplace injuries D. Motor vehicle accidents

Motor vehicle accidents

In the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A. Muscle dexterity B. Muscle tone C. Motor symmetry D. Deep tendon reflexes

Muscle tone

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A. National Institutes of Health Stroke Scale (NIHSS) score B. Race C. LOC at time of admission D. Gender E. Age

National Institutes of Health Stroke Scale (NIHSS) score LOC at time of admission Age

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? A. Pain upon ankle dorsiflexion of the foot B. Neck flexion produces flexion of knees and hips C. Inability to stand with eyes closed and arms extended without swaying D. Numbness and tingling in the lower extremities

Neck flexion produces flexion of knees and hips

A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A. Arrange for the client to receive a low residue diet. B. Position the client upright during feeding. C. Suction the client following each meal. D. Withhold liquids until the client has finished eating.

Position the client upright during feeding

A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? A. Identify the triggers that precipitated the seizure. B. Implement precautions to ensure the client's safety. C. Teach the client's family about the relationship between brain tumors and seizure activity. D. Ensure that the client is housed in a private room.

Implement precautions to ensure the client's safety

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? A. Prepare to transfuse packed red blood cells. B. Prepare for interventions to increase the client's BP. C. Place the client in the Trendelenburg position. D. Prepare an ice bath to lower core body temperature.

Prepare for interventions to increase the client's BP

A client with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? A. Administer bronchodilators as ordered. B. Remind the client of the importance of deep breathing and coughing exercises. C. Prepare to assist with intubation. D. Administer supplementary oxygen by nasal cannula.

Prepare to assist with intubation

A client with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This client's nursing care should involve which of the following? A. Protection of the affected limb from injury B. Passive and active ROM exercises for the affected limb C. Education about improvements to glycemic control D. Interventions to prevent contractures

Protection of the affected limb from injury

The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? A. Suctioning secretions B. Facilitating ABG analysis C. Providing ventilatory assistance D. Administering tube feedings

Providing ventilatory assistance

A 35-year-old client with a history of traumatic brain injury has been admitted to the emergency department for a recent change in cognition. The client is steadily walking across the room, intermittently laughing loudly, and crying hysterically. What is the most likely condition associated with these signs? A. Dementia B. Status epilepticus C. Pseudobulbar affect D. Absence seizure

Pseudobulbar affect

A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's level of consciousness (LOC) is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? A. Recognize that this may represent the peak of postsurgical cerebral edema. B. Alert the surgeon to the possibility of an intracranial hemorrhage. C. Understand that the surgery may have been unsuccessful. D. Recognize the need to refer the client to the palliative care team.

Recognize that this may represent the peak of postsurgical cerebral edema

A client newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the client to implement? A. Perform active ROM exercises three times daily. B. Sleep on a firm mattress. C. Apply cool compresses to the back of the neck daily. D. Wear the cervical collar for at least 2 hours at a time.

Sleep on a firm mattress

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A. Epidural hemorrhage B. Hypertensive emergency C. Spinal shock D. Hypovolemia

Spinal shock

A client has just returned to the unit from the PACU after surgery for a tumor within the spine. The client reports pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position? A. In the high Fowler position B. In a flat side-lying position C. In the Trendelenburg position D. In the reverse Trendelenburg position

In a flat side-lying position

A nurse is planning the care of a 28-year-old client hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client? A. All at one time, to provide a longer rest period B. Before meals, to stimulate the client's appetite C. In the morning, with frequent rest periods D. Before bedtime, to promote rest

In the morning, with frequent rest periods

A gerontologic nurse is advocating for diagnostic testing of an 81-year-old client who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? A. The effects of brain tumors are often attributed to the cognitive effects of aging. B. Brain tumors in older adults do not normally produce focal effects. C. Older adults typically have numerous benign brain tumors by the eighth decade of life. D. Brain tumors cannot normally be treated in clients over age 75.

The effects of brain tumors are often attributed to the cognitive effects of aging

A client is having a "fight or flight response" after receiving a bad disease prognosis. What affect will this have on the client's sympathetic nervous system? A. Constriction of blood vessels in the heart muscle B. Constriction of bronchioles C. Increase in the secretion of sweat D. Constriction of pupils

Increase in the secretion of sweat

The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? A. Using the incentive spirometer as prescribed B. Maintaining the client on bed rest C. Providing aids to compensate for loss of vision D. Assessing frequently for loss of cognitive function

Using the incentive spirometer as prescribed

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? A. Vigilant monitoring of fluid balance B. Continuous BP monitoring C. Serial arterial blood gases (ABGs) D. Monitoring of the client's airway for patency

Vigilant monitoring of fluid balance

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid? A. Washing the face B. Exposing the skin to sunlight C. Using artificial tears D. Drinking large amounts of fluids

Washing the face

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? A. Preparation for emergency craniotomy B. Watchful waiting and close monitoring C. Administration of inotropic drugs D. Fluid resuscitation

Watchful waiting and close monitoring

A client had a lumbar puncture performed at the outpatient clinic and the nurse phoned the client and family that evening. What does this phone call enable the nurse to determine? Select all that apply. A. What the client's and family's expectations of the test are. B. Whether the client's family had any questions about why the test was necessary. C. Whether the client has had any complications from the test. D. Whether the client understood accurately why the test was done. E. The necessary steps for the client and family to take should complications arise.

Whether the client has had any complications from the test. The necessary steps for the client and family to take should complications arise

A client diagnosed with Bell palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles? A. Blowing up balloons B. Deliberately frowning C. Smiling repeatedly D. Whistling

Whistling

The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication? A. Increased muscle strength B. Decreased pain C. Improved GI function D. Improved cognition

Increased muscle strength

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? A. Risk for impaired skin integrity related to immobility and sensory loss B. Impaired physical mobility related to loss of motor function C. Ineffective breathing patterns related to weakness of the intercostal muscles D. Urinary retention related to inability to void spontaneously

Ineffective breathing patterns related to weakness of the intercostal muscles

A family member of a client diagnosed with Huntington disease calls the clinic. The family member is requesting help from the Huntington Disease Society of America. What kind of help can this client and family receive from this organization? Select all that apply. A. Information about this disease B. Referrals C. Public education D. Individual assessments

Information about this disease Referrals Public education

The nurse in the intensive care unit (ICU) is using the neurological assessment flow chart to evaluate a calm client with traumatic brain injury (TBI) that has several medications infusing. Which medication would best allow an accurate assessment of the client's neurological status? A. Lorazepam B. Benzodiazepines C. Propofol D. Midazolam

Propofol

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? A. Computed tomography (CT) scan B. Lumbar puncture C. Magnetic resonance imaging (MRI) D. Venous Doppler studies

Lumbar puncture

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? A. Hydrochlorothiazide B. Furosemide C. Mannitol D. Spironlactone

Mannitol

A family member brings the client to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? "Take your prescribed medication to bring down your sodium levels." "Eat a nutritious diet." "Stop smoking as soon as possible." "Have your heart checked regularly."

"Stop smoking as soon as possible."

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This provides what potential information to the nurse about the client's status? A. The client's level of knowledge about preceding events B. An assessment of the client's current level of consciousness C. An assessment of the client's lowest verbal and physical response to stimuli D. An in-depth and real-time neurological assessment of the client's condition

An assessment of the client's current level of consciousness

A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A. Applying a protective eye shield at night B. Chewing on the affected side to prevent unilateral neglect C. Avoiding the use of analgesics whenever possible D. Avoiding brushing the teeth

Applying a protective eye shield at night

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? A. Naproxen 250 PO b.i.d. B. Calcium carbonate 1,000 mg PO b.i.d. C. Aspirin 81 mg PO o.d. D. Lorazepam 1 mg SL b.i.d. PRN

Aspirin 81 mg PO o.d.

The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this? A. Baclofen B. Dexamethasone C. Mannitol D. Phenobarbital

Baclofen

A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder? A. Urinary retention B. Bladder spasms C. Urge incontinence D. Bladder contract

Bladder contract

A client is being given a medication that stimulates the parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A. Constricted pupils B. Dilated bronchioles C. Decreased peristaltic movement D. Relaxed muscular walls of the urinary bladder

Constricted pupils

A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment? A. Reduction in the appearance of new lesions on the MRI B. Decreased muscle spasms in the lower extremities C. Increased muscle strength in the upper extremities D. Decreased severity and duration of exacerbations

Decreased muscle spasms in the lower extremities

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. Confusion B. Uncertainty C. Depression D. Disassociation

Depression

A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's reported headache? A. Initiating a client-controlled analgesia (PCA) of morphine sulfate B. Administering hydromorphone IV as needed C. Dimming the lights and reducing stimulation D. Distracting the client with activity

Dimming the lights and reducing stimulation

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? A. Disorientation and restlessness B. Decreased pulse and respirations C. Projectile vomiting D. Loss of corneal reflex

Disorientation and restlessness

The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? A. Tinnitus B. Facial paralysis C. Pain at the base of the tongue D. Diplopia

Facial paralysis

A client is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this client, the nurse has the client stick out the tongue and move it back and forth. What is the nurse assessing? A. Function of the hypoglossal nerve B. Function of the vagus nerve C. Function of the spinal nerve D. Function of the trochlear nerve

Function of the hypoglossal nerve

The nurse is caring for a client who is scheduled for a cervical discectomy the following day. During health education, the client should be made aware of what potential complications? A. Vertebral fracture B. Hematoma at the surgical site C. Scoliosis D. Renal trauma

Hematoma at the surgical site

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A. Restrain the client to prevent injury. B. Open the client's jaws to insert an oral airway. C. Place client in high Fowler position. D. Loosen the client's restrictive clothing.

Loosen the client's restrictive clothing

The nurse is caring for a client with increased intracranial pressure (ICP). The client has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document after providing interventions for this diagnosis? A. Registers normal body temperature B. Copes with sensory deprivation C. Obeys commands with appropriate motor responses D. Pays attention to grooming and appearance

Obeys commands with appropriate motor responses

When assessing a 36-year-old male, the nurse gently strokes the client's right palm using a cotton applicator. As the nurse strokes the client's palm the nurse then checks to see if the client will begin to grasp the applicator. This assessment is associated with which of the following reflexes? A. Pathologic B. Superficial C. Deep tendon D. Brachioradialis

Pathologic

Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? A. Positioning the client to avoid intercranial pressure (ICP) B. Maximizing partial pressure of carbon dioxide (PaCO2 ) C. Administering hypertonic intravenous (IV) solution D. Initiating early mobilization

Positioning the client to avoid intercranial pressure (ICP)

A male client presents at the free clinic with reports of erectile dysfunction. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect? A. Prolactinoma B. Angioma C. Glioma D. Adrenocorticotropic hormone (ACTH)-producing adenoma

Prolactinoma

The nurse caring for a client diagnosed with Parkinson disease has helped prepare a plan of care that would include which goal? A. Promoting effective communication B. Controlling diarrhea C. Preventing optic nerve damage D. Managing choreiform movements

Promoting effective communication

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? A. Withholding stimulants 24 to 48 hours prior to exam B. Removing all metal-containing objects C. Instructing the client to void prior to the MRI D. Initiating an IV line for administration of contrast

Removing all metal-containing objects

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? A. Inability to use a wheelchair B. Unable to swallow liquid and solid food C. Incontinent in bowel movements D. Requires full assistance for elimination

Requires full assistance for elimination

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edema B. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking cerebral flow D. To determine the cause of the TIA

To remove atherosclerotic plaques blocking cerebral flow

A male client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of the urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A. Urinary catheter use often leads to urinary tract infections (UTIs). B. Urinary function is permanently lost following an SCI. C. Urinary catheters should not remain in place for more than 7 days. D. Overuse of urinary catheters can exacerbate nerve damage.

Urinary catheter use often leads to urinary tract infections (UTIs)

In which specific instances should the nurse assess the client's cranial nerves? Select all that apply. A. When a neurogenic bladder develops B. When level of consciousness is decreased C. With brain stem pathology D. In the presence of peripheral nervous system disease E. When a spinal reflex is interrupted

When level of consciousness is decreased With brain stem pathology In the presence of peripheral nervous system disease

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A. Young age B. Frequent travel C. African American race D. Male gender E. Alcohol or drug use

Young age Male gender Alcohol or drug use

A nurse is conducting an assessment of a client who is suspected of having a brain tumor. Assessment reveals reports of a headache, for which the nurse gathers additional information. The nurse determines that these reports support the suspicion of a brain tumor when the client reports that the headache occurs: A. early in the morning. B. around lunchtime. C. in the middle of the afternoon. D. at bedtime.

early in the morning

A client is diagnosed with an acoustic neuroma. When assessing this client, which manifestation would the nurse expect to find? Select all that apply. A. tinnitus B. vertigo C. staggering gait D. seizures E. headache

tinnitus vertigo staggering gait

A client for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the client? A. "The test will temporarily limit blood flow through the brain." B. "An allergy to iodine precludes getting the radio-opaque dye." C. "The client will need to endure loud noises during the test." D. "The test may result in dizziness or lightheadedness."

"The test may result in dizziness or lightheadedness."

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. A. Transcranial Doppler flow study B. Cerebral angiography C. MRI D. Cranial radiography E. Electromyography (EMG)

A. Transcranial Doppler flow study B. Cerebral angiography C. MRI

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? A. Alcohol causes hormone fluctuations. B. Alcohol causes vasodilation of the blood vessels. C. Alcohol has an excitatory effect on the CNS. D. Alcohol diminishes endorphins in the brain.

Alcohol causes vasodilation of the blood vessels

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

Alteration in level of consciousness (LOC)

The nurse is caring for a client with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the client's plan of care? A. Firmly redirect the client's head when feeding. B. Administer phenothiazines after each meal as prescribed. C. Encourage the client to keep his or her feeding area clean. D. Apply deep, gentle pressure around the client's mouth to aid swallowing.

Apply deep, gentle pressure around the client's mouth to aid swallowing

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A. Placing the client on a fluid restriction as prescribed B. Administering an antifibrinolytic agent C. Applying thigh-high elastic stockings D. Assisting the client with passive range-of-motion (PROM) exercises

Applying thigh-high elastic stockings

e nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client? A. Assessing the client's verbal response B. Assessing the client's ability to follow complex commands C. Assessing the client's judgment D. Assessing the client's response to pain

Assessing the client's verbal response

A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? A. Botulinum toxin type A and heat B. Baclofen and stretching C. Amitriptyline and splinting D. Corticosteroids and acupuncture

Baclofen and stretching

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures

Bleeding

A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B. Flexor spasm, clonus, and negative Babinski reflex C. Blurred vision, intention tremor, and urinary hesitancy D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

Blurred vision, intention tremor, and urinary hesitancy

The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon? A. Premature degradation of acetylcholine B. Decreased availability of dopamine C. Insufficient synthesis of epinephrine D. Delayed reuptake of serotonin

Decreased availability of dopamine

A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care? A. Cognitive declines B. Personality changes C. Contractures D. Difficulty in coordination

Difficulty in coordination

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? A. Adult failure to thrive B. Post-trauma syndrome C. Hyperthermia D. Disturbed sensory perception

Disturbed sensory perception

During the performance of the Romberg test, the nurse observes that the client sways slightly. What is the nurse's most appropriate action? A. Facilitate a referral to a neurologist. B. Reposition the client supine to ensure safety. C. Document successful completion of the assessment. D. Follow up by having the client perform the Rinne test.

Document successful completion of the assessment

The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect should the nurse assess this client? A. Pruritus B. Dyskinesia C. Lactose intolerance D. Diarrhea

Dyskinesia

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the best determination that the brain's electrical activity has ceased? A. Magnetic resonance imaging (MRI) B. Electroencephalography (EEG) C. Electromyography (EMG) D. Computed tomography (CT)

Electroencephalography (EEG)

The school nurse has been called to the football field, where a player is laying immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A. Ensure that the player is not moved. B. Obtain the player's vital signs, if possible. C. Perform a rapid assessment of the player's range of motion. D. Assess the player's reflexes.

Ensure that the player is not moved

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? A. Falls B. Audio hallucinations C. Respiratory depression D. Labile BP

Falls

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? A. Fluid restriction B. Transfusion of platelets C. Transfusion of fresh frozen plasma (FFP) D. Electrolyte restriction

Fluid restriction

A nurse is performing a neurological assessment on a client at home. During the assessment, the nurse notices that the client has a flat affect. Which lobe of the brain is responsible for a person's affect? A. Parietal lobe B. Temporal lobe C. Frontal lobe D. Occipital lobe

Frontal lobe

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. Frustration around changes in function and communication B. Unmet physiologic needs C. Changes in brain activity during sleep and wakefulness D. Temporary changes in metabolism

Frustration around changes in function and communication

A client has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The client is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? A. Gag reflex B. Deep tendon reflexes C. Abdominal girth D. Hearing acuity

Gag reflex

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A. Unclassified seizure B. Absence seizure C. Generalized seizure D. Focal seizure

Generalized seizure

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A. Hot or cold packs B. Analgesics C. Anti-inflammatory medications D. Whirlpool baths

Hot or cold packs

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? A. How to differentiate between hemorrhagic and ischemic stroke B. Risk factors for ischemic stroke C. How to correctly modify the home environment D. Techniques for adjusting the client's medication dosages at home

How to correctly modify the home environment

A client is exhibiting late signs of increased intracranial pressure. Which finding would the nurse most likely assess? Select all that apply. A. Hypertension B. Bradycardia C. Respiratory depression D. Headache E. Papilledema

Hypertension Bradycardia Respiratory depression

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? A. Hyperthermia B. Tachycardia C. Hypertension D. Bradypnea

Hyperthermia

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows the brain regulates body temperature in which of the following areas? A. Cerebellum B. Thalamus C. Hypothalamus D. Midbrain

Hypothalamus

A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition? A. Chronic confusion B. Impaired urinary elimination C. Impaired verbal communication D. Bowel incontinence

Impaired verbal communication

A client has been recently diagnosed with myasthenia gravis. Which is indicative of a person diagnosed with myasthenia gravis? A. Excessive serotonin activity in the brain B. Decreased dopamine activity in the brain C. Impairment of acetylcholine binding to muscle cells D. Defects in the expression of acetylcholine receptors

Impairment of acetylcholine binding to muscle cells

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? A. Limit the amount of assistance provided with ADLs. B. Collaborate with the physical therapist and immobilize the client's extremities temporarily. C. Increase the frequency of ROM exercises. D. Educate the client about the importance of frequent position changes.

Increase the frequency of ROM exercises

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action? A. Inform the care team and assess for further signs of possible increased ICP. B. Administer bronchodilators as prescribed and monitor the client's LOC. C. Increase the client's bed height and reassess in 30 minutes. D. Administer a bolus of normal saline as prescribed.

Inform the care team and assess for further signs of possible increased ICP

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? A. Intravenous phenobarbital B. Intravenous diazepam C. Oral lorazepam D. Oral phenytoin

Intravenous diazepam

The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition? A. Ischemic stroke B. Decrease inflammation C. Hemorrhagic stroke D. Hypertension

Ischemic stroke

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? A. It suggests onset of metabolic problems. B. It indicates paralysis on the right side of the body. C. It indicates paralysis of cranial nerve X (CN X). D. It indicates an injury at the midbrain level.

It indicates an injury at the midbrain level

The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment? A. Depress the client's tongue with a sterile tongue depressor. B. Ask the client to swallow a small quantity of any soft food. C. Observe the client swallowing a small mouthful of water. D. Lightly touch the client's pharynx with a cotton swab.

Lightly touch the client's pharynx with a cotton swab

A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A. Hemiplegia B. Dry mucous membranes C. Signs of internal bleeding D. Loss of brain stem reflexes

Loss of brain stem reflexes

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? A. Change the client's position as indicated. B. Monitor serum electrolytes. C. Maintain NPO status. D. Monitor arterial blood gas (ABG) values.

Monitor serum electrolytes

The critical care nurse is caring for 25-year-old admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? A. Maintaining the client's functional independence B. Providing health education C. Monitoring neurologic status closely D. Promoting mobility

Monitoring neurologic status closely

Following a spinal cord injury, a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A. Complete the pin site care to decrease risk of infection. B. Notify the neurosurgeon of the occurrence. C. Stabilize the head in a lateral position. D. Reattach the pin to prevent further head trauma.

Notify the neurosurgeon of the occurrence

When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? A. Palpate trapezius muscle while client shrugs shoulders against resistance. B. Administer the whisper or watch tick test. C. Observe for facial movement symmetry, such as a smile. D. Note any hoarseness in the client's voice.

Observe for facial movement symmetry, such as a smile

A client with an inoperable brain tumor has been told that the client has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply. A. Pain control B. Management of treatment complications C. Interpretation of diagnostic tests D. Assistance with self-care E. Administration of treatments

Pain control Management of treatment complications Assistance with self-care Administration of treatments

A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? A. Cerebral cortex B. Temporal lobe C. Central sulcus D. Penumbra region

Penumbra region

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? A. Prednisone B. Dexamethasone C. Cafergot D. Phenytoin

Phenytoin

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? A. Dura mater B. Arachnoid C. Fascia D. Pia mater

Pia mater

A nurse has a client with a spinal cord injury and is tailoring their care plan to prevent the major causes of death for this client. The nurse's care plan includes assisted coughing techniques, a sequential compression device, and prevention of pressure injuries. Which are the most likely possible causes of death for this client? A. Pneumonia, pulmonary embolism, and sepsis B. Cardiac tamponade, hypoxia, and malnutrition C. Oxygen toxicity in paralytic ileus and electrolyte imbalances D. Seizures, osteomyelitis, and urinary tract infections

Pneumonia, pulmonary embolism, and sepsis

A client presents to the clinic reporting a headache. The nurse notes that the client is guarding the neck and tells the nurse about stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? A. Negative Brudzinski sign B. Positive Kernig sign C. Hyperpatellar reflex D. Sluggish pupil reaction

Positive Kernig sign

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.

Provide a board of commonly used needs and phrases

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? A. Hyperactive deep tendon reflexes B. Reduction in cerebral blood flow C. Increased cerebral metabolism D. Hypersensitivity to painful stimuli

Reduction in cerebral blood flow

A client has just been diagnosed with Parkinson disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family? A. Risk for infection B. Impaired spontaneous ventilation C. Unilateral neglect D. Risk for injury

Risk for injury

A 50-year-old female client reports a new onset, moderate headache after a lumbar puncture. What is the most likely condition that the client is experiencing? A. Cranial arteritis B. Cluster headache C. Paroxysmal hemicranias D. Secondary headache

Secondary headache

A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? A. Permanent improvement after 4 to 6 months of treatment B. Symptom improvement that lasts a few weeks after TPE ceases C. Permanent improvement after 60 to 90 treatments D. Gradual improvement over several months

Symptom improvement that lasts a few weeks after TPE ceases

A 48-year-old client has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A. The client will likely require lifelong treatment with anticholinergic medications. B. The client has a disproportionate risk of developing myasthenia gravis later in life. C. The client needs to be assessed for MS. D. The disease is self-limiting and the client will achieve pain relief over time.

The client needs to be assessed for MS

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A. The client should mobilize as soon as physically able. B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C. The client should remain on bed rest until the client expresses a desire to mobilize. D. Lack of mobility will greatly increase the client's risk of stroke recurrence.

The client should mobilize as soon as physically able

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A. The ability of the client to follow instructions during the seizure. B. The success or failure of the care team to physically restrain the client. C. The client's ability to explain his seizure during the postictal period. D. The client's activities immediately prior to the seizure.

The client's activities immediately prior to the seizure

A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. Which assessment finding would rule out discharging the client? A. The client reports a headache. B. The client reports pain at the site where the ball hits his head. C. The client is visibly fatigued. D. The client's speech is slightly slurred.

The client's speech is slightly slurred

A 72-year-old man has been brought to his primary care provider by the client's daughter, who claims that the client has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurse's assessment and management of this client? A. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic. B. Lapses in memory in older adults are considered benign unless they have negative consequences. C. Gradual increases in confusion accompany the aging process. D. Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

Thorough assessment is necessary because changes in cognition are always considered to be pathologic

The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A. The ability to select basic medications for the neurologic dysfunction B. Understanding of the tests used to diagnose neurologic disorders C. Knowledge of nursing interventions related to assessment and diagnostic testing D. Knowledge of the anatomy of the nervous system E. The ability to interpret the results of diagnostic tests

Understanding of the tests used to diagnose neurologic disorders Knowledge of nursing interventions related to assessment and diagnostic testing Knowledge of the anatomy of the nervous system

The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The nurse's communication with the client should reflect the possibility of which sign or symptom of the disease? A. Intermittent hearing loss B. Tinnitus C. Tongue enlargement D. Vocal paralysis

Vocal paralysis

A nurse is reading a journal article about brain tumors and the various types that can occur. The nurse demonstrates understanding of the article by identifying which type as being classified as an intracerebral tumor? Select all that apply. A. meningioma B. schwannoma C. glioblastoma D. astrocytoma E. medulloblastoma

glioblastoma astrocytoma medulloblastoma

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? A. The client received a blood transfusion. B. The client's analgesia regimen was recently changed. C. The client was not repositioned during the night shift. D. The client's urinary catheter became occluded.

The client's urinary catheter became occluded

A client who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the client's vomiting is most consistent with a brain tumor? A. The client's vomiting is accompanied by epistaxis. B. The client's vomiting does not relieve his nausea. C. The client's vomiting is unrelated to food intake. D. The client's emesis is blood-tinged.

The client's vomiting is unrelated to food intake

A health care provider has prescribed a standard electroencephalogram (EEG) test for the client. What general instructions should the nurse provide to the client? Select all that apply A. The procedure generally takes 45 to 60 minutes. B. Please remove all jewelry and any metal objects prior to the procedure C. This procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo D. If you feel nervous about the test I can provide you a light sedative medication to ease your anxiety E. Please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure F. It is required that you withhold taking your anticonvulsant medication 72 hours before the procedure.

The procedure generally takes 45 to 60 minutes This procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo Please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure

A 26-year-old female client, who is breastfeeding a newborn, is due to undergo a computed tomography (CT) scan with dye contrast. What instruction should the nurse provide to the client based on this procedure? A. "Do not breastfeed your baby for two weeks after the procedure as recommended by your provider." B. "Limit your intake of water and alcohol following the procedure." C. "Do not eat or cook any shellfish prior to the procedure." D. "Stop breastfeeding for the time frame given by the provider within the nuclear medicine department."

"Stop breastfeeding for the time frame given by the provider within the nuclear medicine department."

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the nurse's best answer? A. "We are trying to help the client be as useful as possible." B. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible." C. "We aren't here to care for the client the way the hospital staff did; we are here to help the client get better and return home." D. "Rehabilitation means helping clients do exactly what they did before their stroke."

"The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible."

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A. "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." B. "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." C. "The sudden, severe headache increases muscle tone and can cause further nerve damage." D. "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing."

"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

A client with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize? A. Assessment of peripheral nervous function B. Assessment of cranial nerve function C. Assessment of nutritional status D. Assessment of respiratory status

Assessment of nutritional status

A nurse is assessing reflexes in a client with hyperactive reflexes. When the client's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a resting position. How should the nurse document this finding? A. Rigidity B. Flaccidity C. Clonus D. Ataxia

Clonus

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? A. Maintaining accurate records of intake and output B. Maintaining a patent airway C. Inserting a nasogastric (NG) tube as prescribed D. Providing appropriate pain control

Maintaining a patent airway

A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate for which priority intervention? A. Insertion of an intracranial monitoring device B. Treatment with antihypertensives C. Making openings in the skull D. Administration of anticoagulant therapy

Making openings in the skull

The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit? A. Temporal lobe B. Parietal-occipital area C. Inferior-posterior frontal areas D. Posterior frontal area

Parietal-occipital area

The nurse is caring for a 77-year-old client with MS. The client is very concerned about the progress of the disease and what the future holds. The nurse should know that older adult clients with MS are known to be particularly concerned about what variables? Select all that apply. A. Possible nursing home placement B. Pain associated with physical therapy C. Increasing disability D. Becoming a burden on the family E. Loss of appetite

Possible nursing home placement Increasing disability Becoming a burden on the family

The nurse is caring for a client recovering from an ischemic stroke. What intervention(s) best addresses potential complications after an ischemic stroke? Select all that apply. A. Providing frequent small meals rather than three larger meals B. Teaching the client to perform deep breathing and coughing exercises. C. Keeping a urinary catheter in place for the full duration of recovery. D. Limiting intake of insoluble fiber, carbohydrates, and simple sugars. E. Encourage the client to stay in bed and assist with turning and repositioning.

Providing frequent small meals rather than three larger meals Teaching the client to perform deep breathing and coughing exercises

The nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm? A. Seizure B. Hypernatremia C. Airway collapse D. Pneumothorax

Seizure

A trauma client was admitted to the intensive care unit (ICU) with a brain injury that resulted in a change in level of consciousness and altered vital signs. The client subsequently became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? A. Adrenal crisis B. Hypothalamic collapse C. Sympathetic storm D. Cranial nerve deficit

Sympathetic storm

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. A. Absence of pain response B. Apnea C. Coma D. Absence of brain stem reflexes E. Absence of deep tendon reflexes

Apnea Coma Absence of brain stem reflexes

A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache? A. As soon as the client's pain becomes unbearable B. As soon as the client senses the onset of symptoms C. Twenty to 30 minutes after the onset of symptoms D. When the client senses his or her symptoms peaking

As soon as the client senses the onset of symptoms

The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? A. Assess the client's vital signs and correlate these with the client's baselines. B. Assess the client's eye opening and response to stimuli. C. Document that the client currently lacks a level of consciousness. D. Facilitate diagnostic testing in an effort to obtain objective data.

Assess the client's eye opening and response to stimuli

A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift? A. Assessing all body surfaces and documenting skin integrity every 8 hours B. Turning and repositioning the client every 6 hours C. Providing skin care with barrier care ointments once a day D. Assisting the client to get out of bed to a chair four times a day.

Assessing all body surfaces and documenting skin integrity every 8 hours

A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A. Encourage the client to increase his/her intake of water and juice. B. Assist the client out of bed and into the chair for meals. C. Instruct the client to tuck his/her chin towards their chest when swallowing. D. Request a swallowing assessment by a speech therapist before the client's discharge E. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

Assist the client out of bed and into the chair for meals Instruct the client to tuck his/her chin towards their chest when swallowing

To alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. What health education should the nurse provide to the client before initiating this treatment? A. Concurrent use of calcium supplements is contraindicated. B. Blood levels of the drug must be monitored. C. The drug is likely to cause hyperactivity and agitation. D. Carbamazepine can cause tinnitus during the first few days of treatment.

Blood levels of the drug must be monitored

A nurse is educating a group of nursing students about signs and symptoms of a hemorrhagic stroke. Which is true of hemorrhagic stroke? A. Occurs with vascular occlusion. B. Is also known as thrombotic stroke. C. Can be known as lacunar strokes. D. Can occur in the subarachnoid space.

Can occur in the subarachnoid space

A client with a history of epilepsy is admitted preoperatively for a surgical procedure and dies overnight. The health care provider suspects sudden unexpected death in epilepsy (SUDEP). Which condition is most likely related to SUDEP? A. Brain aneurysm B. Undiagnosed sepsis C. Cardiac abnormalities D. Seizure medication overdose

Cardiac abnormalities

A 35-year-old client is being admitted to the intensive care unit (ICU) for increased observation with a brain injury and is awake, alert, and disoriented to time and situation. The client sustained a fall from a roof, and x-rays are pending. The nurse would anticipate which supportive priority measures for this client? A. Seizure prophylaxis and prevention B. Cervical and spinal immobilization C. Fluid and electrolyte maintenance D. Intubation and mechanical ventilation

Cervical and spinal immobilization

The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A. Change the client's position frequently. B. Provide a high-protein diet. C. Provide light massage at least daily. D. Teach the client deep breathing and coughing exercises.

Change the client's position frequently

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first? A. Check the client's indwelling urinary catheter for kinks to ensure patency. B. Lower the HOB to improve perfusion. C. Administer PRN analgesia as prescribed. D. Reassure the client that headaches are expected during recovery from spinal cord injuries.

Check the client's indwelling urinary catheter for kinks to ensure patency

A client is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? A. Serial assessments of hemoglobin levels B. Blood glucose monitoring C. Close monitoring of fluid balance D. Assessment of pain along dermatomes

Close monitoring of fluid balance

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement? A. Administer a benzodiazepine at bedtime each night. B. Do not disturb the client between 2200 and 0600. C. Cluster overnight nursing activities to minimize disturbances. D. Ensure that the client does not sleep during the day.

Cluster overnight nursing activities to minimize disturbances

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. A. Contractures B. Hemorrhage C. Pressure ulcers D. Venous thromboembolism E. Pneumonia

Contractures Pressure ulcers Venous thromboembolism Pneumonia

The emergency room (ER) nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding(s) are suggestive of a basilar skull fracture? Select all that apply A. Epistaxis B. Swelling of the tongue and lips C. Bruising over the mastoid D. Unilateral facial numbness E. Severe back pain

Epistaxis Bruising over the mastoid

A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal? Establish a timed voiding schedule Administer anticholinergic drugs as prescribed Perform intermittent catheterization q6h Avoid foods that change the pH of urine

Establish a timed voiding schedule

The nurse in an extended care facility is planning the daily activities of a client with post-polio syndrome. The nurse recognizes the client will best benefit from physical therapy when it is scheduled at what time? A. Immediately after meals B. In the morning C. Before bedtime D. In the early evening

In the morning

The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment? A. Decreased muscle tone B. Flaccid paralysis C. Loss of voluntary control of movement D. Slow reflexes

Loss of voluntary control of movement

A client is scheduled for a myelogram, and the nurse explains to the client that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? A. Lumbar puncture B. MRI C. Cerebral angiography D. EEG

Lumbar puncture

The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? A. MS is a progressive demyelinating disease of the nervous system. B. MS usually occurs more frequently in men. C. MS typically has an acute onset. D. MS is sometimes caused by a bacterial infection.

MS is a progressive demyelinating disease of the nervous system

A client is admitted to the neurologic intensive care unit (ICU) with a suspected diffuse axonal injury. Which primary neuroimaging diagnostic tool would be used on this client to evaluate the brain structure? A. Magnetic resonance imaging (MRI) B. Positron emission tomography (PET) scan C. X-ray of the head D. Ultrasound of the head

Magnetic resonance imaging (MRI)

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? A. Position the client supine. B. Maintain head of bed (HOB) elevated at 30 to 45 degrees. C. Position client in prone position. D. Maintain bed in Trendelenburg position.

Maintain head of bed (HOB) elevated at 30 to 45 degrees

A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension? A. Administer an IV bolus of normal saline prior to repositioning. B. Maintain bed rest until normal BP regulation returns. C. Monitor the client's BP before and during position changes. D. Allow the client to initiate repositioning.

Monitor the client's BP before and during position changes

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply. A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT D. Salt-wasting syndrome E. Increased ICP

Orthostatic hypotension Autonomic dysreflexia DVT

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? A. Restrain the client as ordered. B. Administer opioids PRN as prescribed. C. Arrange for friends and family members to sit with the client. D. Pad the side rails of the client's bed.

Pad the side rails of the client's bed

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? A. Position the client the high Fowler position as tolerated. B. Administer osmotic diuretics as prescribed. C. Participate in interventions to increase cerebral perfusion pressure (CPP). D. Prepare the client for craniotomy.

Participate in interventions to increase cerebral perfusion pressure (CPP)

A client presents at the clinic with pain and weakness in the hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what condition? A. Guillain-Barré syndrome B. Myasthenia gravis C. Trigeminal neuralgia D. Peripheral nerve disorder

Peripheral nerve disorder

A client is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the client may have required surgery on what neurologic structure? A. Cerebellum B. Hypothalamus C. Pituitary gland D. Pineal gland

Pituitary gland

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? A. Place the client in a side-lying position. B. Pad the client's bed rails. C. Administer antianxiety medications as prescribed. D. Reassure the client and family members.

Place the client in a side-lying position

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Keep the lighting in the client's room low. B. Place the client's clock on the affected side. C. Approach the client on the side where vision is impaired. D. Place the client's extremities where the client can see them.

Place the client's extremities where the client can see them

A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by the diagnosis and the known complications of the disease. How can the client best make known their wishes for care as the disease progresses? A. Prepare an advance directive. B. Designate a most responsible health care provider (MRP) early in the course of the disease. C. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. D. Ensure that witnesses are present when he provides instruction.

Prepare an advance directive

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A. Taking a hot bath at least once daily B. Resting in an air-conditioned room whenever possible C. Increasing the dose of muscle relaxants D. Avoiding naps during the day

Resting in an air-conditioned room whenever possible

A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Ischemic stroke B. Right hemispheric stroke C. Hemorrhagic stroke D. Left hemispheric stroke

Right hemispheric stroke

A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 11 / 2 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A. Risk for impaired skin integrity B. Risk for injury C. Risk for autonomic dysreflexia D. Risk for suffocation

Risk for injury

A client with Parkinson disease is undergoing a swallowing assessment because the client has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method? A. Total parenteral nutrition (TPN) B. Provision of a low-residue diet C. Semisolid food with thick liquids D. Minced foods and a fluid restriction

Semisolid food with thick liquids

A rapid response and stroke alert/code has been called for a client with deep vein thrombosis (DVT) of the left leg being treated with intravenous heparin. The client's international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F (37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89% on room air. What are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? A. Immediate intubation and urinary catheter placement B. Supplemental oxygen and monitoring blood glucose levels C. Antipyretics in order to keep the client in a state of hypothermia D. Antihypertensive medications and vital signs every two hours

Supplemental oxygen and monitoring blood glucose levels

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply. INR above 1.0 Symptom onset greater than 5 hours prior to admission Current anticoagulation therapy Sudden symptom onset Recent intracranial pathology

Symptom onset greater than 5 hours prior to admission Current anticoagulation therapy Recent intracranial pathology

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for a serious headache. C. Take antihypertensive medication as prescribed. D. Drowsiness is normal for the first week after discharge.

Take antihypertensive medication as prescribed

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? A. The client should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

The client should be approached on the side where visual perception is intact

A client with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine for pain relief. What principle applies to the administration of this medication? A. Carbamazepine is not known to have serious adverse effects. B. The client should be monitored for bone marrow depression. C. Side effects of the medication include renal dysfunction. D. The medication should be first taken in the maximum dosage form to be effective.

The client should be monitored for bone marrow depression

The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? A. The client's hip joint should be maintained in a flexed position. B. The client should be in a supine position unless ambulating. C. The client should be placed in a prone position for 15 to 30 minutes several times a day. D. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.

The client should be placed in a prone position for 15 to 30 minutes several times a day

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? A. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B. Elevation of the arm and hand can lead to further complications associated with edema. C. Passively exercising the affected extremity is avoided in order to minimize pain. D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder

A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? A. The nurse gives direction to get out of bed but the client does not understand. B. The client points and gestures to an object needed on the overhead table. C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. D. The client sits up and turns to one side to see the object and states what is needed.

The client starts by saying "good morning" but finishes with saying "good day" to the nurse

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioning C. Early initiation of physical therapy D. Absolute bed rest in a quiet, non stimulating environment

Absolute bed rest in a quiet, non stimulating environment

A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? A. Cyclosporine B. Acyclovir C. Cyclobenzaprine D. Ampicillin

Acyclovir

A 69-year-old client is brought to the ED by ambulance because a family member found the client lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. A. Obtain a blood type and cross-match. B. Administer antipyretics as prescribed. C. Perform frequent neurologic assessments. D. Monitor pain levels and administer analgesics. E. Place the client in positive pressure isolation.

Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics

A client is recovering from intracranial surgery performed approximately 24 hours ago and is reporting a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate? A. Administer morphine sulfate as prescribed. B. Reposition the client in a prone position. C. Apply a hot pack to the client's scalp. D. Implement distraction techniques.

Administer morphine sulfate as prescribed

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? A. Monitoring of pulse oximetry B. Administration of a low-protein diet C. Administration of thorough oral hygiene D. Fluid restriction as prescribed

Administration of thorough oral hygiene

The nurse caring for an 80-year-old client knows that the client has a preexisting history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation? A. Damage to cranial nerve VIII B. Adverse medication effects C. Age-related neurologic changes D. An undiagnosed cerebrovascular disease in early adulthood

Age-related neurologic changes

A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? A. Homonymous hemianopsia B. Receptive aphasia C. Agnosia D. Hemiplegia

Agnosia