M/S Exam 2 Review

Describe the corneal reflex response and what does it detect/test? a) introduce ice water into the external auditory canal. Normal- eyes deviate to the side of water introduction. Tests oculovestibular response. b) touch the client's cornea with a wisp of cotton. Normal- blinking. Reveals brain stem function. c) turn the client's head suddenly while holding the eyelids open. Normal-eyes move from side to side when head is turned; abnormal-eyes remain fixed. Detects cranial nerve compression. d) shine a bright light into the client's pupil. Normal- pupil constricts. Evaluates brain stem and cranial nerve III function.

b) touch the client's cornea with a wisp of cotton. Normal- blinking. Reveals brain stem function.

Describe the oculocephalic reflex and what does it detect/test? a) introduce ice water into the external auditory canal. Normal- eyes deviate to the side of water introduction. Tests oculovestibular response. b) touch the client's cornea with a wisp of cotton. Normal- blinking. Reveals brain stem function. c) turn the client's head suddenly while holding the eyelids open. Normal-eyes move from side to side when head is turned; abnormal-eyes remain fixed. Detects cranial nerve compression. d) shine a bright light into the client's pupil. Normal- pupil constricts. Evaluates brain stem and cranial nerve III function.

c) turn the client's head suddenly while holding the eyelids open. Normal-eyes move from side to side when head is turned; abnormal-eyes remain fixed. Detects cranial nerve compression.

A nurse is caring for a client who underwent a lumber laminectomy 2 days ago. Which finding requires immediate intervention? a) an increase in back pain b) a mild fever (less than 101.0F) c) urinary retention or incontinence d) paresthesia in the dermatomes near the wounds

c) urinary retention or incontinence

A client is receiving an I.V. infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? a) decreased LOC b) elevated blood pressure c) decreased heart rate d) increased urine retention

d) increased urine retention *the therapeutic effect of mannitol is diuresis*

Which intervention will the nurse implement first for a client diagnosed with a spinal cord injury who reports sweating and a severe, pounding headache. a) assess for bladder distension b) assess respiratory rate and pulse oximetry and auscultate lung sounds c) administer hydralazine hydrochloride d) place the client in a sitting position

d) place the client in a sitting position *this client is experiencing symptoms of autonomic dysreflexia. The priority intervention is to place the client in a sitting position to decrease blood pressure. The other interventions may be appropriate for this client after the client is sitting.

How should a nurse teach the client to administer their eyedrops based on this prescription? pilocarpine ophthalmic solution, 0.25% gtt i, OU q.i.d.

instilling one drop of pilocarpine 0.25% into both eyes four times daily *"gtt" stands for drop; "i" is the apothecary symbol for the number 1; "OU" signifies both eyes ("OS" left eye, "OD" right eye); "q.i.d." means four days per day*

Normal ICP (intracranial pressure)

0-15 mmHg

The nurse is caring for a client admitted with seizures. Which nursing action is most important when caring for a client during a postictal state? Select all that apply. a) keeping the client side lying b) padding the side rails c) restraining the client d) keeping a bite block close e) setting up suction

a) keeping the client side lying, b) padding the side rails, & e) setting up suction

What is the therapeutic effect of nicardipine (Cardene)? a) decrease systemic hypertension b) decrease cerebral edema c) prevent seizures

a) decrease systemic hypertension

Match each symptom set with left or right hemispheric stroke. a) slow, cautious behavior b) lack of awareness of deficits

a) slow, cautious behavior - Left brain stroke (also causes ride-sided paralysis or weakness) b) lack of awareness of deficits - Right brain stroke (also causes left-sided weakness and left homonymous hemianopsia)

A client has an impairment of cranial nerve II. Which safety precautions must the nurse implement? Select all that apply. a) NPO until a swallow eval has been completed b) clear any obstacles in a path for walking c) provide only cooled beverages d) instruct on the use of a wheeled walker

b) clear any obstacles in a path for walking & d) instruct on the use of a wheeled walker *Cranial nerve II is the optic nerve. Other choices are not reflective of the function of CNII*

What is the therapeutic effect of mannitol (Osmitrol)? a) decrease systemic hypertension b) decrease cerebral edema c) prevent seizures

b) decrease cerebral edema

The nurse is caring for a client with a subdural hematoma. Which is the priority outcome? a) restore blood pressure to the normal range b) ensure airway patency and optimal oxygen levels and protect from injury c) ensuring adequate nutrition, hydration, and elimination d) taking measures to promote skin integrity

b) ensure airway patency and optimal oxygen levels and protect from injury *because there is rapid progression of the subdural hematoma with changes in consciousness, the priority is to maintain airway patency as relaxation of the tongue and jaw may result in obstruction*

A client with quadriplegia is in spinal shock. What should the nurse expect?

absence of reflexes along with flaccid extremities

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a) Kernig's sign b) a positive edrophonium test c) Brudzinski's sign d) a positive sweat chloride test

b) a positive edrophonium test *sweat chloride is used to confirm cystic fibrosis, Kernig's and Budzinski's signs are used to confirm meningitis*

What is the therapeutic effect of phenytoin (Dilantin)? a) decrease systemic hypertension b) decrease cerebral edema c) prevent seizures

c) prevent seizures

Positioning for lumbar puncture

lateral recumbent, with chin resting on flexed knees