Medical surgical neurosensory (adaptive quizzes)

A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect? (Select all that apply.)

[B] stiff neck [C] photophobia [E] lethargy

A nurse is reinforcing teaching with a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? all that apply.)

[D] driving can be dangerous due to loss of peripheral vision. [E] laser surgery can help reestablish the flow of aqueous humor

A nurse in an urgent care center is collecting data from a group of clients who all have an of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse report first to the charge nurse?

a client who is difficult to arouse and is unable to respond to questions.

A nurse is reinforcing teaching with a client who has a new diagnosis of multiple sclerosis (MS). The client asks the nurse about the usual course of MS. Which of the following responses

acute episodes are usually followed by remissions which can last varying lengths of time

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

add gesture when speaking with the client

A nurse is assisting with preparing a client for an electroencephalogram (EEG). When the client asks the nurse what this test does, which of the following responses should the nurse make?

an EEG record the electrical activity of your brain cells.

A nurse is reinforcing teaching about auras with a client who has a new diagnosis of simple partial seizures. Which of the following statements by the client indicates an understanding of the teaching?

an aura is a sensory warning that a seizure is imminent

A nurse is caring for a client who has received sedation. When the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the

arousal

A nurse is reinforcing teaching with a client who has a new diagnosis of Meniére's disease. Which of the following instructions should the nurse include in the teaching?

avoid sudden movements

A nurse is assisting with triaging clients during a mass casualty event. Which of the following laiæls should the nurse assign to a client who has a head injury with fixed, dilated pupils?

black tag

A nurse is reinforcing discharge teaching with a client who had a transient ischemic attack (T IA). The nurse should instruct the client to monitor which of the following parameters at home?

blood pressure

A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client to fall, the nurse should interpret this finding as a positive Romberg test, indicating which of the following alterations?

cerebellar dysfunction

A nurse responds to a call from an assistive that a client has had a seizure and is unconscious. Which of the following data should the nurse collect first?

check airway patency

A nurse is collecting data from a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with of apnea. This client is experiencing which of the following types of

cheyene-stokes

A nurse in an urgent care clinic is collecting data from a client who sustained a fall. Which of the following findings should the nurse identify as an indication of a skull fracture?

clear fluid coming form the nares

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

cochlea

A nurse is reinforcing teaching with a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?

darken the lights

A nurse is collecting data from an older adult client for physiological changes that can occur with aging. Which of the following findings should the nurse expect?

decreased sense of taste.

A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affect the manner in which the nurse will prepare the client for the scan?

developed hives when eating shrimp

A nurse in a rehabilitation center is collecting data from a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect?

difficulty with speech

A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings is an indication the client is experiencing increased intracranial pressure?

dilated pupils

A nurse is collecting data from a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve (CN VIII)?

dizziness and hearing loss

A nurse is collecting data from a client who has a brain tumor. Which of the following findings indicates cranial nerve involvement?

dysphagia

A nurse is reinforcing teaching about degenerative complications with the partner of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority?

dysphagia

A nurse is assisting with the care of a client during the first 72 hours following a cerebrovascular accident (CVA). Which of the following actions should the nurse take?

elevate the head of the bed by 25 to 30 with the client in a neutral midline position

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings is consistent with this diagnosis?

elevated protein

A nurse is caring for a client with a history of repeated middle ear infections. The client says, "My doctor told me these infections are due to an obstruction of the structure that connects the middle ear to the throat." The nurse should identify that the provider is referring to which of the following structures?

eustachian tube

A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during the visit but does not verbally to questions. The nurse should document this finding as which of the following alterations?

expressive aphasia

A nurse is caring for a client who has a hearing impairment. Which of the following actions should the nurse take when communicating with the client?

face the client when speaking

A nurse is reinforcing with a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

feeling of fullness in the ear

A nurse is caring for a client who had a stroke and has expressive aphasia. The nurse should identify that the stroke affected which of the following lobes of the client's brain?

frontal

A nurse is preparing to test the function of cranial nerve X for a client. Which of the following assessment procedures should the nurse use?

have the client open his mouth and say "aah"

A nurse is assisting with the care of a client who has a cerebral lesion and develops hyperthermia. The nurse should identify that which of the following areas of the brain is affected?

hypothalamus

A nurse is reinforcing teaching with a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the teaching?

i will avoid bending over

A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. After 5 minutes, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory?

immediate

A nurse is assisting with caring for a client who has a head injury from a fall at work. After checking the client's airway, breathing, and circulation (ABC), which of the following actions is the priority for the nurse to perform?

immobilize the client cervical spine

A nurse is collecting data from a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment?

inability to locate eye glasses.

A nurse is collecting data from a client who has increased intracranial pressure and has received intravenous mannitol. The nurse should identify that which of the following findings indicates a therapeutic effect of this medication?

increased urine output

A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

instill a diluted alcohol solution into the ear after swimming

A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery?

intraocular hemorrhage

A nurse is collecting data from a client who is admitted to to the facility for observation following a closed head injury. Which of the following data is the priority for the nurse to collect to detect a change in the client's neurological status?

level of consiousness.

A nurse is reinforcing teaching with the family of a client who has stage II Alzheimer's disease (AD). Which of the following pieces of information should the nurse include in the teaching?

limit choices offered to the client.

A nurse is collecting data from a client who has cataracts. Which of the following findings should the nurse expect?

opacity visible behind the pupil

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside?

oral nasal suction equipment.

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse take next?

place the client in a high flower position

A nurse is reinforcing discharge teaching with the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first if a seizure occurs?

protect the clients head

A nurse is caring for a client who has an impairment of cranial nerve II. The nurse should do which of the following to ensure the client's safety?

provide an obstacle free path for ambulation

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty?

reading the newspaper

During a neurological evaluation, a nurse asks how the client arrived at the appointment and with whom. Which of the following types of memory is the nurse testing?

recall

A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take?

redirect the client to a different activity with a small group of people

A nurse is reinforcing discharge teaching with a client who had a transient ischemic attack (TIA), Which of the following instructions should the nurse include?

reduce dietary sodium

During a neurological evaluation, a nurse asks a client to name all of his children and state their ages and their birth dates. Which of the following types of memory is the nurse testing?

remote

A nurse is collecting data from a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia?

report of a headache

A nurse is assisting with the care of a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor?

respiratory effort

A home health nurse is interviewing the adult child of a client who has Alzheimer's disease. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Which of the following referrals should the nurse make for the caregiver?

respite care

A nurse is collecting data from a client who has an acute visual disturbance, describing a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?

retinal detachment.

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect?

right -sided hemiplegia

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure (ICP). The nurse should identify that this elevated ICP is due to which of the following?

rigid skull containing cranial content

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

sclerosis of the ossicles

A nurse is caring for a client who has a closed head injury. The nurse should place the client in which of the following positions?

semiflowers

A nurse is reinforcing teaching for a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of information should the nurse provide?

set an alarm to ensure medication dosage are taken on time.

A nurse is collecting data from a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?

severe eye pain

A nurse is reinforcing teaching with a client who is going to have an electroencephalogram (EEG) in the morning. Which of the following information should the nurse provide the client?

shampoo your hair before the procedure and don't use any styling products afterwards

A nurse is collecting data from a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?

swelling behind the affected ear

A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following data is the nurse's priority to collect?

the client ability to clear oral secretions

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

the client has a pacemaker

A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect to find when collecting data from this client?

the client is unable to understand words or sentences he hears.

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?

the client rigidly extends his arms.

A nurse is reinforcing teaching with a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching?

thoroughly shampoo the hair prior to the EEG

A nurse is reinforcing teaching with a client about treatment options for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants?

transmits impulses directly to auditory nerve endings

A nurse is caring for a client who takins to have a generalized tonic-clonic seizure while lying in Which of the following actions should the nurse take?

turn the client onto the side

A nurse is caring for a client who is experiencing a seizure while in bed Which of the following actions should the nurse take?

turn the clients head to the side

A nurse is reinforcing teaching with the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following findings is an early manifestation of ALS?

weakness of the distal extremities.

A nurse is collecting data from a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect?

weakness of the lower extremities.

A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

widening pulse pressure

A nurse is reinforcing teaching with a group of clients about transient ischemic attacks (TIE. Which of the following information should the nurse include in the teaching?

A TIA can precede an ischemic stroke

A nurse is assisting with the plan of care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the plan of care?

Monitor the client for increased intracranial pressure

A nurse is collecting data from a client who reports vision loss that began with a 'flash of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders?

retina detachment.

A nurse is collecting data from a client with recent head trauma who has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (Dl). Which of the following laboratory values should the nurse plan to obtain to monitor for Dl?

specific gravity

A nurse is reinforcing discharge teaching with a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching?

you should expect to see flashing lights in front of the affected eye after the procedure.

A nurse is assisting with preparing a client for an electroencephalogram (EEG). Which of the following directions should the nurse provide to the client?

you'll begin by lying still with your eyes closed

A nurse is reinforcing teaching with a client about computed tomography (CT) scanning of the brain. Which of the following pieces of information should the nurse include?

you'll have to lie very still on a long narrow table during the test

A nurse is reinforcing teaching with a client who is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include?

your procedure will only take 10 or 15 minutes for each eye.

A nurse is collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates the medication is having a therapeutic effect?

the client urine output is 250 ml/hr