MSII Neuro 1

A nurse is reinforcing teaching for client who has a Myelogram. Which of the following statements indicate that the client understands?

" I will not to eat or drink anything for 8 hours before the procedure."

A nurse is reinforcing teaching with a client who is scheduled for a CT scan of the head with contrast. Which of the following statements by the client should the nurse identify as understanding of this teaching?

- "I can take medications up to 2 hrs before the procedure."

A nurse is caring for a client with a lumbar puncture. What is the action the nurse should take?

- provide oral fluids - monitor nausea, -sensation of toes -Level of consciousness

A nurse caring for a client with MG knows that the medical and nursing care for this client includes all the following interventions: (Hint: respiratory, airway)

-Anticholinesterase drugs (prostigmin, mestinon, tensilon) -Mechanical ventilation (observe for aspiration, suction as needed) -Airway techniques for swallowing: chin tuck, double swallow -Feed patient on high-Fowler's position

A nurse in a community center is assisting with an educational session for caregivers of older adult clients who have dementia. Which of the following topics should the nurse include in the teaching session?

-actions to reduce stress - social support system available -community resources -legal services

A nurse is in a long term care facility and is performing mental status exam for newly admitted client who has dementia. Which of the following data should the nurse include?

-include grooming - long term memory -affect

A nurse is performing mental status exam(MSE). The nurse includes which of the following?

-the ability to perform calculation -level of LOC -depressing suicidal thoughts -the level of orientation

A nurse is on a Medical surgical unit and checking the bowel sounds for a client with epilepsy and begins to experience a tonic clonic seizure. Indicate the sequence of steps the nurse should follow:

1 -check injuries 2 -reorientate and reassure client 3 -remain with the client 4 -call for help 5 -place the client in lateral position

A nurse is caring for a client who has epilepsy and has a new prescription for lamotrigine. For which of the following findings should the nurse withhold the medication and notify the provider? (Side effect)

double/blurred vision dizziness h/a, N/V serious skin rashes

The nurse has received report on a group of clients. Which client requires the nurse's attention first?

A young adult who has experienced 4 tonic-clonic seizures in 30 mins (=> status epilepticus)

A nurse is collecting data from a school age child who is undergoing a neurological assessment following a head injury. The nurse should include or document gross incoordination when walking as which of the following findings?

Ataxia

A nurse is reinforcing teaching for a client who has multiple sclerosis and has a new prescription for baclofen. Which of the following instructions should the nurse include? Avoid what?

Avoid activities that require alertness until CNS effects of drug is known

A nurse is providing morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse take?

Be calm and offer some music (something to calm the patient)

A nurse is assessing a client with a neurological condition who is reporting difficulty chewing. The nurse suspects that which cranial nerve is affected?

CN V - Trigeminal nerve

A nurse is assessing a client who is recovering from a cerebral angiography via client's right femoral artery. Which of the assessments should the nurse complete?

Check for pedal pulses

A patient is receiving an osmotic diuretic. Which of the following nursing interventions should the nurse implement for a client receiving this type of medication?

Check the urine output Check the electrolytes Check daily weights (same time/clothes, before meals)

Caring for a client with a concussion following a motor vehicle crash. The nurse should monitor the client for which of the following early manifestations of increased intracranial pressure?

Decreased LOC is the earliest sign Diplopia, Headache, Pupillary signs

A client injured in an automobile accident is being evaluated in the ER for possible head injury. What test should not be done if there is an indication of increased intracranial pressure? (Choices: Lumbar puncture, MRI, CT scan, Electroencephalogram)

Do not perform a lumbar puncture (may lead to brain herniation)

A client is recovering from head injury. A nurse determines that the client understands measure to prevent elevation of intracranial pressure if the nurse observes the client doing the following activities?

Eating high fibers than using enemas and laxatives

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client is demonstrating decorticate posturing. Which of the following findings should the nurse expect to observe?

have a plantar flexion of the legs

A nurse is contributing to the plan of care for a client experiencing headaches following administration of spinal anesthesia for spinal surgery. The nurse should:

Encourage intake of fluids

A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? (When to take it)

Evenly spaced intervals during the day

A 45-year old patient with myasthenia gravis and is brought to the emergency room. Which of the following statements should the nurse ask the client in obtaining her initial assessment? (S/sx?)

Eyelid drooping and double vision Weakness of muscles of the extremities Difficulty chewing or swallowing Bladder and bowel incontinence

The nurse is dealing with dementia patient. What should the nurse include in teaching?

Forgetfulness gradual progression to disorientation

A nurse is reinforcing discharge teaching for a client who has multiple sclerosis. Which of the following instructions should the nurse include?

Give them time to rest

A client has a lumbar puncture procedure. What is the client's position?

Lateral (side) position with the knee and head flexed at an acute angle

A nurse is assessing a client with Parkinson's disease during mealtime. Which of the following actions is inappropriate? (Options are as follows)

Limit the length of mealtime

Demyelination of the myelin sheath throughout the brain stem, spinal cord, optic nerves and cerebrum causing the destruction of the myelin sheath: What do you call that disease?

Multiple sclerosis

Lumbar puncture: What will be the nursing observation that will cause the nurse of most concern?

Oozing fluid on the injection site

A nurse is caring for 4 clients in a neurologic ICU. After receiving the handoff report, which of the clients should the nurse see first?

Patient with Glasgow coma scale score declining

Parkinson's disease. What do they exhibit?

Pin-rolling motions of fingers Shuffling gait Tremor, rigidity and bradykinesia

The nurse enters the client's room to administer morning medication and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?

Place the client in a side-lying position

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury which results in increased intracranial pressure. Which of the following is the appropriate nursing action?

Place them in a room with reduced stimulation

A client presents with a history of migraine headache. Which of the subjective data is likely to be obtained either from the health history or during the physical examination to support the diagnosis?

Pounding pain Photosensitivity Unusual smells/sounds; visual field defects; disorientation Worse on one side of head N/V

A nurse is caring for a patient taking sumatriptan for migraines who reports that she is positive for pregnancy.

Sumatriptan is contraindicated during pregnancy; use another type of migraine med

A nurse is collecting data from a client who is 6 day post craniotomy from removal of inter cerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

hypertension

As a result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would describe the patient's inability to assess the spatial position of his body?

Proprioception

What will be included in your plan for a patient with seizure disorder?

Side rails up Suction equipment ready at bedside Oxygen readily available

Medication for Parkinson's disease to increase the level of dopamine:

Sinemet (carbidopa-levodopa)

A nurse delegates care for the UAP. Which statement should the nurse when delegating care for a client with CN II (optic nerve) impairment?

Tell the client where are the food items

A 35-year old man who suffers from tension headache asks for clarification concerning why he hasn't been given a narcotic for pain even though he finds the headache painful and debilitating. Based on your knowledge, you understand that:

Tension headache reacts best with acetaminophen rather than narcotics. The patient does not necessarily need a narcotic medication.

Client is at risk for increased intracranial pressure. The nurse is monitoring the client for manifestations that indicate the pressure is...

The nurse should check the function of CN III - Oculomotor nerve

A nurse is Caring for client who takes lasix. Which of the following adverse effects should the nurse monitor for?

hyypokalemia

A client is admitted to the emergency with Parkinson's disease. Which of the following statements of the daughter would support the diagnosis of Parkinson's disease?

The patient has repetitive questions and asks where he placed his toothbrush

Progression of Alzheimer's disease is commonly divided into four stages. By the time the person reaches the 3rd stage, which of the characteristics are most likely to be exhibited?

Total disorientation to person, place and time Apraxia (inability to carry learned movements, purposeful acts or use objects properly) Wandering Visual agnosia (inability to recognize objects by sight) Dysgraphia (difficulty communicating via writing)

A nurse is collecting data from a client who has a prescription for several daily medications. They are taking ginkgo biloba, ginger, and garlic. The nurse should inform the client that these herbal preparations can cause which medication interaction?

increases effect of oral anticoagulant

A nurse is contributing to the plan of care of a patient with dementia. Which of the following is appropriate to include in the plan of care?

limit client's choices for daily activity

The nurse is caring for a client who has ingestion poison and is now having seizures. Which of the following requires priority action by the nurse?

maintain patent airway

A nurse is contributing to the plan of care for a client who had a craniotomy. Which of the following interventions should the nurse include in the plan?

maintain seizure precaution

A nurse is reinforcing teaching with a family of a client with a new diagnosis of dementia. Which of the following information should the nurse include in the teaching?

manifestations of dementia are progressive and irreversible

A nurse is caring for a toddler who is going to have a lumbar puncture. Which of the following actions should the nurse take?

place toddler in side-lying knee chest position

A nurse is collecting data for client who is beginning to take lasix. Which of the following laboratory is priority?

potassium

A nurse is contributing to the plan of care for a client with dementia. Which of the following actions should the nurse include in the plan of care?

provide consistent daily routine

A nurse is collecting data from a client who has a traumatic head injury to determine motor function response, which of the following client's response to painful stimuli is within normal limits?

push painful stimuli away

A nurse is caring for patient with dementia whose family says they wander at night. Nursing action?

put personal items within their reach take client to the bathroom frequently (keeps them from getting up at night)

A nurse is Preparing a client for an for MRI. Which of the following statements should the nurse include when reinforcing the teaching ?

remove metal objects such as watches and body jewelry.

A nurse is reinforcing teaching for a client with multiple sclerosis and has a new prescription for baclofen. Which of the following information should the nurse include in the teaching?

should help with sx of muscle spasms

A patient with early stage of dementia is oriented to name and place and usually cooperative. What is the appropriate nursing action if they refuse their medications?

"What's your reason?"

A 49-year old with myasthenia gravis. Which of the following statements made by the client indicates poor understanding of myasthenic crisis?

When they say that most of the time they will be staying in bed

Know about medication for MG (best choice)

Anticholinesterase drugs: neostigmine (Prostigmin) and pyridostigmine (Mestinon)

A client presents with an acute exacerbation of MS. Which prescribed medication should the nurse administer to control the symptoms by reducing the edema and inflammation of the site of the demyelination?

Antiinflammatory (e.g. steroid: -sone)

Client with Huntington's disease: Which assessment findings should the nurse expect to find?

Chorea - abnormal and excessive involuntary movements Including affected facial movements (speech, chewing and swallowing) Ataxia (loss of full control of movements) Deteriorating gait => ambulation becomes impossible Deterioration in mental function Intellectual decline Emotional lability Psychotic behavior

A nurse is collecting data with a client who has myasthenia gravis. Which of the following findings is the highest priority for this patient?

Watch for respiratory paralysis (ineffective breathing pattern)

A Nurse is reviewing the data of client with a head injury. The following findings should indicate the client may have Diabetes Mellitus Insipidus?

a urine output of 650 mL/hr

A patient has Parkinson's Disease and gets nauseated. Which food to take?

applesauce

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

apply bed alarm to client's bed

A Nurse at provider's office is reviewing the medication record of a client with mild dementia. The client's caregiver reports the client takes ginkgo biloba to aid his memory. The nurse should warn the caregiver to monitor and report for which of the following adverse effects?

bleeding gums

A Nurse is receiving a transfer report for a client who has a head injury. The Glasgow Coma Scale score is 3 for eye opening, 5 for best verbal, 5 for motor response. Which of the following is an appropriate conclusion based on this data?

client opens his eyes when spoken to

A Nurse is caring for client who has dementia and scheduled for a procedure? Which of the following individuals should the nurse request to sign the client's informed consent?

client's son with durable power of attorney

A Nurse is collecting data from a client who had a recent closed head injury. The nurse should recognize which of the following findings is a priority to report?

difficulty speaking

Nurse is reinforcing teaching with a client who takes benztropine to treat Parkinson's Disease. The nurse should instruct client which is an adverse effect of the medication?

difficulty voiding

A nurse is contributing to plan of care for client who has increased intracranial pressure following a closed head injury. Which of the following interventions should the nurse recommend?

elevate HOB

The nurse is assisting in care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take?

encourage fluid intake monitor puncture site

A nurse is contributing to the plan of care for a client with a Lumbar puncture. Which of the following interventions should the nurse include?

encourage fluids

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

give them a familiar item ( dolls, bear)

A Nurse is collecting data from a client who has severe dementia and a fractured femur due to a fall. Which of the following manifestations should the nurse understand is a physical finding and acute pain?

increase pulse rate

A nurse is monitoring a client for findings related to diabetes insipidus following a craniotomy. Which of the following findings should indicate a manifestation of this condition to the nurse?

increased urine output

A nurse is caring for client who has epilepsy and a new prescription of lamotrigine. Which of the following findings should the nurse instruct the client to withhold medication and notify the doctor?

skin rash

The nurse is collecting data for a client who has Parkinson's Disease and is experiencing bradykinesia. Which of the following findings should the nurse expect?

slurred speech

A nurse is preparing Home instructions for a client with epilepsy. Which of the following informations should the nurse include in the teaching?

take showers rather tub baths

A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day, which of the following instructions should the nurse include?

the nurse should include repeatedly ask client questions to check for orientation

The client has a score of 8 using the glasgow coma scale. Which of the following findings should the nurse expect?

total nursing care