Med surg neuro
A nurse is contributing to the plan of care for a client who has dysphagia and a new dietary prescription. Which of the following nursing interventions should the nurse include in the plan?
Placing food on the unaffected side of the clients mouth will allow her to have better control of the food and reduce aspiration The client should be given liquids that are thicker than water to prevent aspiration Suction equipment should be available in case of choking and aspiration. The client should be taught to flex her neck, tucking the chin down and under to close the epiglottis during swallowing
A client is suspected to have a neuromuscular disorder, however your accurate historical assessment revealed something the resident missed. This client is recently recovering from a viral illness and received their immunizations, you also not that the weakness is ascending because the client stated, "It started in my feet and hands and is moving up my body it seems, and it's difficult to even take two steps, and yesterday I was walking fine." You immediately notify the physician of your assessment findings because:
You suspect Guillian Barre, are concerned about this client's respiratory status, and ask if he would like to order additional labs
A nurse is assisting with the care of a client following surgical evacuation of a subdural hematoma. Which of the following data is the PRIORITY to monitor?
Oxygen saturation
The client with spinal cord injury suddenly is experiencing an episode of autonomic dysreflexia. After checking the vital signs which immediate action should the nurse take?
Sit client up in bed, remove noxious stimuli,
A client comes into the ER with left side facial droop, unable to raise their eyebrow, and states, "I am recovering from the flu I had last week." What cranial nerve would you assess?
7th cranial nerve
A nurse is collecting data from a client who has increased intracranial pressure (ICP). Which of the following findings should the nurse expect?
Headache Unequal pupils Restless and irritability Disorientation to time and place
Dopaminergic medications stimulate the dopamine receptors for Parkinson's patients, and is classifies as an anticholinergic medication - What would be an adverse affect the nurse would monitor for in a patient who is on an anticholinergic medication?
Impaired voluntary movements
A nurse is collecting data from a client who reports a stiff neck and a severe headache. Data collection reveals a positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform FIRST?
Implement droplet precautions
A nurse is contributing to the care of a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following interventions should the nurse recommend? (Select all that apply)
Monitor for impaired extraocular movements Implement seizure precautions Turn off room lights and television
The nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which if the following actions should the nurse take to check for this manifestation?
Have the client stand erect with his eyes closed
A nurse is reinforcing discharge instructions with a female client who has a prescription for phenytoin. Which of the following information should the nurse include?
Take the medication at the same time everyday
A nurse is reinforcing teaching with the family of the client who is receiving bromocriptine for his parkinson's. Which of the following statements by the family member should the nurse identify as understanding of the teaching?
This medication can cause dizziness
A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse?
"It is limited to brain tissue"
A nurse is caring for a client who is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse take to decrease the potential for raising the client;s ICP? (Select all that apply.)
Decrease the noise level in the clients room
A lethargic, yet easily aroused 6-year-old child is brought to the emergency department with a diagnosis of an overdose with diazepam. During the initial data collection, the nurse determines that the child's blood pressure and respirations are below normal for his age. The Glasgow Coma Scale is performed and reveals a score of 10. Based on this information the nurse determines that which problem should have the highest priority?
Altered respiratory status
A nurse is caring for the client with increased intracranial pressure. Which change in vital signs would occur if the ICP is rising?
Increasing body temperature, decreasing pulse, decreasing respiration, increasing BP
The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred?
Infiltration
A nurse is caring for a client who just had a generalized seizure. Which of the following actions should the nurse perform FIRST?
Keep the client in a side lying position
A nurse is checking for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take? (Select all that apply.)
Place hands behind clients neck Place client in supine position Bend clients head towards chest
A nurse is collecting data from a client who has a seizure disorder. The client reports sensing an aura and is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.)
Provide privacy Loosen the clients clothing Ease the client to the floor of standing Protect the clients head with padding Move furniture away from client
You are caring for a client who had just suffered a right sided stroke, and you are teaching the family what to expect prior to discharge. What would you include in your teaching? (select ALL THAT APPLY)
They may exhibit impulse control they may exhibit loss of depth perception, they may develop disuse of their left side
A nurse is caring for a client who has experienced a right hemispheric stroke. Which of the following findings should the nurse expect?(select all that apply)
They will exhibit a lack of awareness to surroundings They will exhibit left sided hemiplegia The client will exhibit depth perception A client who has experienced a right hemispheric stroke can exhibit impulse control difficulty, such as urgency to use the bathroom
You suspect your patient has trigeminal neuralgia, what assessment findings would you report to the physician?
This patient is unable to eat or drink, has severe pain noted along the 5th cranial nerve, and also states she is unable to sleep and even the air hurts her face
A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?
Transfusion reaction
A nurse is contributing to the plan of care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following interventions should the nurse recommend? (select all that apply.)
Turn off room lights and tv Monitor for impaired extraocular movements Implement seizure precautions
The nurse is contributiong to the care of a client with global aphasia (both receptive and expressive)Which of the following interventionsshould the nurse include in the client's plan? (select all that apply)
Use flash card with pictures Give instructions one step at a time Speak to the client at a slower rate
A nurse is reviewing a prescription for dexamethasone with a client who has an expanded brain tumor. Which of the following are appropriate statements by the nurse?
Reduce swelling of the brain Can cause fluid retention May notice weight gain You will need to monitor your blood sugar
A nurse is contributing to the care of a client who has stage IV parkinson's disease. Which of the following actions should the nurse include in the plan of care?
Record diet and fluid intake daily Offer nutritional supplements between meals
