NCLEX 10000 Neurosensory disorders

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? a) "Don't eat anything for 12 hours before the test." b) "Avoid thinking about personal matters for 12 hours before the test." c) "Don't shampoo your hair for 24 hours before the test." d) "Avoid stimulants and alcohol for 24 to 48 hours before the test."

"Avoid stimulants and alcohol for 24 to 48 hours before the test." Explanation: For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results.

The nurse is teaching a young woman about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client states: a) "I must weigh myself weekly to check for sudden gain in weight." b) "I will use one of the barrier methods of contraception." c) "I will need a higher dose of oral contraceptive when on this drug." d) "Since I am 28 years old, I should not delay starting a family.

"I will use one of the barrier methods of contraception." Correct Explanation: An alternative or additional method of birth control must be used because oxcarbazepine reduces the effectiveness of oral contraceptives. Higher doses of oral contraceptives will not help in achieving this purpose, but the client needs an additional or alternative method of birth control. The client does not need advice about when to start a family. A side effect of oxcarbazepine may be weight gain, but it is typically gradual.

When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of: a) 10 to 20 mm Hg. b) 5 to 10 mm Hg. c) over 30 mm Hg. d) 20 to 30 mm Hg.

10 to 20 mm Hg. Correct Explanation: Normally, pressure in the anterior chamber of the eye remains relatively constant at 10 to 20 mm Hg.

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? a) Activity level will be restricted for several months; the client should plan on being sedentary. b) Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks. c) Activity level can return to normal; clients can resume regular aerobic exercises. d) Activity level is determined by the client's tolerance; clients can be as active as they wish.

Activity is resumed gradually; the client can resume usual activities in 5 to 6 weeks. Correct Explanation: The scarring of the retinal tear needs time to heal completely. Therefore, resumption of activity should be gradual; the client may resume usual activities in 5 to 6 weeks. Successful healing should allow the client to return to a previous level of functioning

An elderly client has suffered a cerebrovascular accident (CVA). The right side of the client's face has visible ptosis. The nurse would be alert to which of the following?

Dysphagia Correct Explanation: Dysphagia is difficulty swallowing. The same nerve that controls the drooping of the face can cause dysphagia. The other choices are not associated with CVA. Agenesis is absence or incomplete development of an organ or body part. Epistaxis is a nose bleed. Xerostomia is a dry mouth

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 level of consciousness (LOC) b) Decreased heart rate c) Elevated blood pressure d) Increased urine output

Increased urine output Correct Explanation: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

Which goal is a priority for a client who has undergone surgery for retinal detachment? a) Control pain. b) Maintain a darkened environment. c) Prevent an increase in intraocular pressure. d) Cleanse the eye with soap and water.

Prevent an increase in intraocular pressure. Correct Explanation: After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal. Control of pain with analgesics is a secondary goal. The client should avoid getting soap and water in the eye when bathing. Maintaining a darkened environment is not necessary for this client

A client is scheduled for a prostatectomy, and the anesthetist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthetist's instructions. Why does the client require special positioning for this type of anesthesia? a) To prevent confusion b) To prevent cerebrospinal fluid (CSF) leakage c) To prevent cardiac arrhythmias d) To prevent seizures

To prevent cerebrospinal fluid (CSF) leakage Correct Explanation: The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning doesn't help prevent confusion, seizures, or cardiac arrhythmias.

A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which area that is a potential pressure point when the client is in this position? a) heel b) ankles c) sacrum d) occiput

ankles Correct Explanation: Common pressure points in the side-lying position include the ears, shoulders, ribs, greater trochanter, medial and lateral condyles, and ankles. The sacrum, occiput, and heel are pressure points in the supine position

To assess a client's cranial nerve function, a nurse should assess: a) orientation to person, time, and place. b) hand grip. c) arm drifting. d) gag reflex.

gag reflex. Correct Explanation: The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to: a) use a condom catheter instead of an invasive one. b) insert an indwelling urinary catheter c) place the client on fluid restrictions. d) increase the frequency of the catheterizations.

increase the frequency of the catheterizations. Explanation: As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.

A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy? a) appetite b) alertness c) muscle rigidity d) mood

muscle rigidity Correct Explanation: Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson's disease.

The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply. a) Eat a low-purine diet. b) Limit fluid intake to no more than 1 L/day. c) Eat a high-purine diet. d) Limit alcohol intake. e) Eat a high-protein diet, with at least two servings of lean meat per day.

• Eat a low-purine diet. • Limit alcohol intake. Explanation: Gout is characterized by an abnormal metabolism of uric acid. Individuals either produce too much uric acid or their body is unable to metabolize and excrete it. Purines are metabolized into uric acid. The client who suffers from gout would be placed on a low-purine diet with foods such as peanut butter, cherries, rice, pasta, fruits, and vegetables. Fluids do not have to be limited. Alcohol intake would be limited as it is thought to trigger an exacerbation.

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? a) "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." b) "Try to ambulate independently after about 24 hours." c) "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." d) "Shampoo your hair every day for 10 days to help prevent ear infection."

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." Explanation: The nurse should instruct the client to avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes) for 30 days after a stapedectomy. Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The client's first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry.

The nurse observes that the client with multiple sclerosis looks untidy and sad. The client suddenly says, "I cannot even find the strength to comb my hair," and bursts into tears. Which response by the nurse is best? a) "How many days have you been unable to comb your hair?" b) "Why has your husband not been helping you?" c) "It must be frustrating not to be able to care for yourself." d) "Tell me more about how you are feeling."

"Tell me more about how you are feeling." Correct Explanation: By asking the client to tell more about how she is feeling, the nurse is not making any assumptions about what is troubling the client. The nurse should acknowledge the client's feelings and encourage her to discuss them. Saying that this situation must be frustrating involves assumptions by the nurse about why the client is crying and is not a therapeutic response. Asking how long the client has been unable to comb her hair takes the focus off her feelings and inhibits therapeutic communication. Inquiring why the client's husband has not helped insinuates that the husband is not helping enough, which is inappropriate, takes the focus off the client's feelings, and inhibits therapeutic communication.

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability? a) "I can participate in sexual activity but might not experience orgasm." b) "I should be able to participate in sexual activity, but I will be infertile." c) "I will not be able to have sexual intercourse until the urinary catheter is removed." d) "I cannot have sexual intercourse because it causes hypertension, but other sexual activity is okay."

"I can participate in sexual activity but might not experience orgasm." Explanation: The woman with spinal cord injury can participate in sexual activity but might not experience orgasm. Cessation in the nerve pathway may occur in spinal cord injury, but this does not negate the client's mental and emotional needs to creatively participate with her partner in a sexual relationship and to reach orgasm. An indwelling urinary catheter may be left in place during intercourse and need not be removed because the indwelling urinary catheter is placed in the urethra, which is not the channel used for sexual intercourse. There are no contraindications, such as hypertension, to sexual activity in a woman with spinal cord injury. Sexual intercourse is allowed, and hypertension should be manageable. Because a spinal cord injury does not affect fertility, the client should have access to family planning information so that an unplanned pregnancy can be avoided.

Three years ago, a client was diagnosed with multiple sclerosis. He now presents with lower extremity weakness and heaviness. During the admission process, the client presents his advance directive that states he doesn't want intubation, mechanical ventilation, or tube feedings, should his condition deteriorate. How should the nurse respond? a) "Advance directives aren't necessary for a client your age." b) "It's important for us to have this information. You should review the document with your physician at every admission." c) "You're too young and your disease hasn't progressed enough to follow an advance directive." d) "Thank you for providing this document; I'll include it with your permanent record."

"It's important for us to have this information. You should review the document with your physician at every admission." Correct Explanation: An advance directive should be part of the client's medical record. The client should review the document with the physician at every admission because some conditions may be reversible and temporary, making portions of the advance directive inappropriate. Simply telling the client that the document will be included in his permanent record doesn't address the need to review the directive with the physician. Advance directives are appropriate for clients of any age

A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? a) "Drug interactions are the most common cause of dementia in the elderly." b) "Dementia is a terrible disease of the elderly." c) "Depression may manifest as dementia in elderly clients." d) "The most common cause of dementia in the elderly is Alzheimer's disease."

"The most common cause of dementia in the elderly is Alzheimer's disease." Correct Explanation: The nurse should inform the family member that Alzheimer's disease is the most common cause of dementia in elderly clients. Dementia is a clinical manifestation, not a disease process. Although drug interactions and overmedication are causes of dementia, these causes aren't as common as Alzheimer's disease. Depression is common in elderly clients, but it doesn't cause dementia

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time he's admitted to the intensive care unit (ICU) for aggressive treatment. She's meeting with the team to develop a change strategy using indicators. Which statement by a team member indicates a need for further teaching regarding performance management? a) "We can review ED staffing to see if shortages affect ICU admission." b) "We can collaborate with staff from the ED and the ICU to formulate strategies and implement change." c) "We can use statistics gathered in the ED during triage to determine the average time for admission to the ICU." d) "We can discipline the ED staff for not getting the clients to the ICU fast enough."

"We can discipline the ED staff for not getting the clients to the ICU fast enough." Correct Explanation: Using statistics and other indicators, such as ED staffing information, to develop a change strategy is part of performance management. Disciplining staff doesn't reflect a strategy based on indicators. Collaborating with staff from other areas results in performance improvement, not performance management.

A 70-year-old, previously well client asks the nurse, "I notice I have tremors. Is this just normal for my age?" What should the nurse tell the client? a) "You should report this to the health care provider because it may indicate a problem." b) "You should drink orange juice when this occurs." c) "I would not be worried, because this is common with aging." d) "You should have your blood pressure checked when this occurs."

"You should report this to the health care provider because it may indicate a problem." Correct Explanation: Fine tremors are the first symptom reported in 70% of clients with Parkinson's disease. A new onset of tremors needs to be investigated by the health care provider. Tremors are not an expected change with aging.

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client: a) "You may drink fluids until midnight, but after that drink nothing until the scan is completed." b) "You will have some hair shaved to attach the small electrode to your scalp." c) "You will need to hold your head very still during the examination." d) "You must shampoo your hair tonight to remove all oil and dirt."

"You will need to hold your head very still during the examination." Explanation: The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea. There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? a) Administering a stool softener as ordered b) Encouraging oral fluid intake c) Suctioning the client once each shift d) Elevating the head of the bed 90 degrees

Administering a stool softener as ordered Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first? a) Watch the client or a family member administer the drug to determine possible contamination sources. b) Advise the client to discard the drug because it may have undergone chemical changes or become contaminated. c) Advise the client to keep the container closed tightly and protected from light. d) Advise the client to obtain a fresh container of pilocarpine solution to avoid omitting ordered doses.

Advise the client to discard the drug because it may have undergone chemical changes or become contaminated. Correct Explanation: A cloudy solution indicates that the drug has changed chemically or has become contaminated. Therefore, the nurse first should advise the client to discard the drug. Advising the client to obtain a fresh container of pilocarpine, watching the client or a family member administer the drug, and advising the client to keep the container closed tightly and protected from light are all appropriate actions to take after telling the client to discard the solution.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client? a) An isolation room three doors from the nurses' station b) A semiprivate room with a client who has viral meningitis c) A two-bed room with a client who previously had bacterial meningitis d) A private room down the hall from the nurses' station

An isolation room three doors from the nurses' station Correct Explanation: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease

What should the nurse do when administering pilocarpine (Pilocar)?

Apply pressure on the inner canthus to prevent systemic absorption. Explanation: When administering pilocarpine, the nurse should apply pressure on the inner canthus to prevent systemic absorption of the drug. Pilocarpine doesn't cause night blindness. The outer canthus doesn't absorb eyedrops, so applying pressure there won't be helpful. Flushing the client's eye with normal saline solution after administering pilocarpine is contraindicated because it will wash the drug out of the eye, rendering treatment ineffective.

A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer? a) Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU. b) Tell the ICU they have to wait to transfer the client because everyone is too busy to accept the client. c) Notify the supervisor that the client care assignment is unsafe with the addition of the new client, and insist she assist with the assignment. d) Administer the medications quickly and ask the nursing assistant and LPN to finish providing care for the clients.

Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU. Explanation: The registered nurse should use the ancillary staff to help effectively manage the group of clients. While the registered nurse accepts the client from the ICU, the nursing assistant can provide care for the clients, and the LPN can administer the remaining medications. Telling the ICU to wait or notifying the supervisor that she must assist are incorrect options because the nurse should assess the situation and use the ancillary staff appropriately. The nurse has adequate staff to safely provide care for this group of clients. The nurse shouldn't administer medications quickly because haste is an unsafe practice that could lead to a medication error. Instead of rushing, the nurse should delegate the responsibility to the LPN.

A client undergoes intense rehabilitation after a cerebrovascular accident (CVA) and is being discharged with residual hemiparesis. What is the most important responsibility of the case manager? a) Reinforce the importance of optimal nutritional intake and increased fluid intake to promote recovery. b) Assess and reduce fall risk factors and implement measures to prevent a subsequent CVA. c) Assess capabilities, demonstrate the use of assistive devices, and assess how the client will manage at home. d) Assess ability to perform instrumental activities of daily living and reinforce the importance of preventing complications of immobility.

Assess capabilities, demonstrate the use of assistive devices, and assess how the client will manage at home. Correct Explanation: As a result of the CVA, and with residual hemiparesis, it is important to assess capability and ensure safety with use of assistive devices. To ensure safety, the home situation needs to be assessed to determine if the client can manage. Discharge teaching will involve assessing fall risk factors. Preventing a subsequent CVA is not as important as preparing for safe management at home. The client is mobile, so immobility complications should not be the focus. Nutrition and fluid information is secondary in importance

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? a) Pupillary asymmetry b) Declining level of consciousness (LOC) c) Involuntary posturing d) Irregular breathing pattern

Declining level of consciousness (LOC) Correct Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an I.V. injection of a medication. What is the medication the nurse tells the client he'll receive during this test? a) Immunoglobulin G b) Azathioprine c) Cyclosporine d) Edrophonium

Edrophonium Explanation: The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms.

After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders pilocarpine ophthalmic solution, 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: a) instilling one drop of pilocarpine 0.25% into the left eye four times daily. b) instilling one drop of pilocarpine 0.25% into both eyes daily. c) instilling one drop of pilocarpine 0.25% into the right eye daily. d) instilling one drop of pilocarpine 0.25% into both eyes four times daily.

Explanation: When administering pilocarpine, the nurse should apply pressure on the inner canthus to prevent systemic absorption of the drug. Pilocarpine doesn't cause night blindness. The outer canthus doesn't absorb eyedrops, so applying pressure there won't be helpful. Flushing the client's eye with normal saline solution after administering pilocarpine is contraindicated because it will wash the drug out of the eye, rendering treatment ineffective.

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear? a) External ear b) Tympanic membrane c) Inner ear d) Middle ear

Inner ear Correct Explanation: A client with vertigo experiences problems with the inner ear, which is responsible for maintaining equilibrium. The external ear collects sound; the middle ear conducts sound. The tympanic membrane (eardrum) vibrates in response to sound stimulation

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which of the following nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions? a) Eat foods containing vitamins C, D, and E, and drink at least 2 L of fluid a day. b) Drink a large amount of fluids, especially milk products, and eat a diet that includes multiple sources of vitamin D. c) Eat foods and ingest fluids that will cause the urine to be less acidic. d) Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.

Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. Correct Explanation: Increasing fluid intake will provide an internal irrigation and dilute the urine. This will lessen the probability of renal calculi forming. Cranberry juice is helpful in acidifying the urine and lessening the incidence of cystitis. Ingesting large amounts of milk and vitamin D will not decrease incidence of a UTI or renal calculi. Foods containing vitamins will not necessarily prevent these problems, nor will less acidic urine.

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first? a) Ask family members to stay with the client. b) Administer a sedative. c) Increase the frequency of client observation. d) Contact the health care provider (HCP), and request a prescription for soft wrist restraints.

Increase the frequency of client observation. Correct Explanation: The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible and/or delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family is able to stay with the client, that is an option, but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually potentiate the problem.

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action? a) Jugular vein distention b) Weight loss c) Polyuria d) Tetanic contractions

Jugular vein distention Correct Explanation: Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Keeping the client in one position to decrease bleeding b) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess c) Maintaining the client in a quiet environment d) Positioning the client to prevent airway obstruction

Keeping the client in one position to decrease bleeding Correct Explanation: The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding

A nurse is assessing a client with meningitis. The nurse places the client in a supine position and flexes the client's leg at the hip and knee. The nurse notes resistance when straightening the knee and the client reports pain. The nurse should document what neurologic sign as positive? a) Brudzinski's sign b) Babinski's reflex c) Lichtheim's sign d) Kernig's sign

Kernig's sign Explanation: A positive Kernig's sign is a manifestation of meningeal irritation. The nurse can elicit this sign by placing the client in a supine position and flexing the leg at the hip and knee. Pain or resistance when the knee is straightened suggests meningeal irritation. Babinski's reflex — dorsiflexion of the great toe with extension and fanning of the other toes — is an abnormal reflex elicited by firmly stroking the lateral aspect of the feet with a blunt object. Babinski's reflex is an indicator of corticospinal damage. A positive Brudzinski's sign (flexion of the hips and knees in response to positive flexion of the neck) also signals meningeal irritation. Lichtheim's sign is the inability to speak associated with subcortical aphasia

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? a) Supine, with the knees raised toward the chest b) Lateral recumbent, with chin resting on flexed knees c) Lateral, with right leg flexed d) Prone, with the head turned to the right

Lateral recumbent, with chin resting on flexed knees Correct Explanation: To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with knees flexed toward the chin. The needle is inserted between L4 and L5. The other positions wouldn't allow as much space between L4 and L5.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate? a) Encephalitis b) Increased intracranial pressure (ICP) c) Meningeal irritation d) Low cerebrospinal fluid (CSF) pressure

Meningeal irritation Explanation: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign and Kernig's sign don't indicate increased ICP, encephalitis, or low CSF pressure.

A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which of the following? a) Meningitis b) Paralytic ileus c) Pneumonia d) Renal failure

Meningitis Correct Explanation: Head trauma and fractures place an individual at high risk for meningitis. A client who is febrile with increasing drowsiness should be investigated for posttraumatic meningitis. It is unlikely that pneumonia, renal failure, or a paralytic ileus would occur as a result of a basal skull fracture.

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate? a) Muscle contraction is palpable and visible. b) Muscles move actively against gravity alone. c) Muscle contraction or movement is undetectable. d) Normal, full muscle strength is present.

Muscle contraction is palpable and visible. Explanation: Muscle strength is assessed and rated on a five-point scale in all four extremities, comparing one side to the other. Palpable, visible muscle contraction on the affected side and normal, full muscle strength on the unaffected side indicate a rating of 1/5. Normal, full muscle strength on both sides is rated 5/5. Active muscle movement against gravity alone on the affected side with normal, full muscle strength on the unaffected side is rated 3/5. Undetectable muscle contraction or movement on the affected side with normal, full muscle strength on the unaffected side is rated 0/5.

What assessment findings would the nurse expect to find with a client with progressive myasthenia gravis? a) Muscle inflammation, choking when eating, nearsightedness, and painful joints b) Atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving c) Muscle weakness, difficulty swallowing, double vision, and difficulty speaking d) Muscle pain, difficulty speaking, headaches, and arthritic changes

Muscle weakness, difficulty swallowing, double vision, and difficulty speaking Correct Explanation: With myasthenia gravis there is a disturbance in nerve transmission to the muscles. The signs and symptoms in this answer reflect this neuromuscular impairment. The other answers include signs and symptoms not related to neuromuscular impairment, such as atrophy, muscle inflammation, headaches, and arthritic changes.

What assessment findings would the nurse expect to find with a client with progressive myasthenia gravis? a) Muscle weakness, difficulty swallowing, double vision, and difficulty speaking b) Muscle inflammation, choking when eating, nearsightedness, and painful joints c) Muscle pain, difficulty speaking, headaches, and arthritic changes d) Atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving

Muscle weakness, difficulty swallowing, double vision, and difficulty speaking Correct Explanation: With myasthenia gravis there is a disturbance in nerve transmission to the muscles. The signs and symptoms in this answer reflect this neuromuscular impairment. The other answers include signs and symptoms not related to neuromuscular impairment, such as atrophy, muscle inflammation, headaches, and arthritic changes.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? a) Temporal b) Frontal c) Parietal d) Occipital

Occipital Explanation: The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture

The nurse is completing a neurologic assessment on a client who has been admitted with a contusion to the brain. Which of the following findings would warrant further action? a) Pupils are equal and sluggish in reaction to light. b) The client moves away from noxious stimuli. c) The client responds to verbal commands. d) Hand grasps are strong and equal.

Pupils are equal and sluggish in reaction to light. Correct Explanation: Assessing the pupillary response is an important consideration in neurologic assessment. When pupils are sluggish to respond, this indicates neurologic impairment. The Glasgow Coma Scale is used to assess the extent of neurologic impairment. Each of the other findings indicates a normal response to stimuli. Vital signs are normal.

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests? a) Transesophageal echocardiogram (TEE), troponin levels, and a complete blood count b) Electrocardiography, TEE, prothrombin time (PT), and International Normalized Ratio (INR) c) X-ray of the brain, bone marrow aspiration, and EEG d) EEG, blood cultures, and neuroimaging studies

Remain in a semi-Fowler's position. Explanation: The nurse should instruct the client to remain in a semi-Fowler's position or on the nonoperative side. Positioning the feet higher than the body does not affect the operative eye; placing the head in a dependent position could increase pressure within the eyes

The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use? a) Lie on the operative side. b) Position the feet higher than the body. c) Place the head in a dependent position. d) Remain in a semi-Fowler's position.

Remain in a semi-Fowler's position. Explanation: The nurse should instruct the client to remain in a semi-Fowler's position or on the nonoperative side. Positioning the feet higher than the body does not affect the operative eye; placing the head in a dependent position could increase pressure within the eyes

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? a) Respiratory alkalosis b) Metabolic alkalosis c) Metabolic acidosis d) Respiratory acidosis

Respiratory acidosis Correct Explanation: Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.

When assessing a client who has had spinal anesthesia, which finding is expected? a) The blood pressure is significantly increased. b) The client reports a headache while in the lying position. c) The client feels pain before moving the legs. d) Sensation returns to the toes first and then progresses to the perineal area.

Sensation returns to the toes first and then progresses to the perineal area. Correct Explanation: Spinal anesthesia is an extensive conduction nerve block that is produced when a local anesthetic is introduced into the subarachnoid space at the lumbar level. A few minutes after induction of a spinal anesthetic, anesthesia and paralysis affect the toes and perineum and then, gradually the legs and abdomen. When the autonomic nervous system is blocked, vasodilation occurs and hypotension occurs. The client will feel sensation to the toes before the perineal area. A spinal headache due to loss of fluid is a severe headache that occurs while in the upright position, but is relieved in the lying position

When administering metoclopromide for vomiting related to migraine headaches, the nurse notices that the client has continuous movements of tongue and lip smacking after taking this medication. The nurse should a) Instruct the client to take the medication early in the morning before breakfast. b) Administer the medication to the client with food. c) Stop the medication and notify the health care provider. d) Withhold the medication until the unusual movements come to a stop.

Stop the medication and notify the health care provider. Correct Explanation: Metoclopramide, a prokinetic agent used as an antiemetic, has central antiemetic effects and antagonizes the action of dopamine, a catecholamine neurotransmitter. It can cause serious muscle problems called tardive dyskinesia (extrapyramidal effect) in which the client's muscles, especially of the face, move in unusual ways. Tardive dyskinesia may not be reversible. This medication must be stopped, and the nurse should notify the health care provider immediately. Administering the medication with food, withholding the medication until movements come to a stop, or taking the medication early in the morning will not stop the extrapyramidal side effects of the medication

When administering metoclopromide for vomiting related to migraine headaches, the nurse notices that the client has continuous movements of tongue and lip smacking after taking this medication. The nurse should a) Withhold the medication until the unusual movements come to a stop. b) Administer the medication to the client with food. c) Instruct the client to take the medication early in the morning before breakfast. d) Stop the medication and notify the health care provider.

Stop the medication and notify the health care provider. Explanation: Metoclopramide, a prokinetic agent used as an antiemetic, has central antiemetic effects and antagonizes the action of dopamine, a catecholamine neurotransmitter. It can cause serious muscle problems called tardive dyskinesia (extrapyramidal effect) in which the client's muscles, especially of the face, move in unusual ways. Tardive dyskinesia may not be reversible. This medication must be stopped, and the nurse should notify the health care provider immediately. Administering the medication with food, withholding the medication until movements come to a stop, or taking the medication early in the morning will not stop the extrapyramidal side effects of the medication.

A client returns from surgery after a submucosal resection with nasal packing in place. The nurse should first: a) assess the client's appetite. b) assess the degree of airway obstruction. c) observer ecchymosis in the periorbital region. d) determine the degree of pain the client is experiencing.

assess the degree of airway obstruction. Correct Explanation: Postoperative nursing assessment of the client after nasal surgery focuses on early detection of complications. Two common complications are airway obstruction and hemorrhage. The nasal packing can slip out of position and occlude the client's airway. Therefore, assessing the client for airway obstruction is a priority assessment. Assessing pain is important, but assessing for airway obstruction is the highest priority. Ecchymosis will not develop immediately after surgery. Assessing the client's appetite immediately after surgery is not a high priority.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? a) Trigeminal neuralgia b) Bell's palsy c) Migraine headache d) Angina pectoris

Trigeminal neuralgia Explanation: Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris

The client with a head injury receives mannitol during surgery to help decrease intracranial pressure. Which finding indicates that the drug is having the desired effect? a) Pulse rate decreases. b) Muscular relaxation increases. c) Urine output increases. d) Blood pressure decreases.

Urine output increases. Correct Explanation: Mannitol is an osmotic diuretic that helps decrease intracranial pressure through its dehydrating effects. The drug is acting in the desired manner when urine output increases. It may be desirable to decrease pulse rate, decrease blood pressure, or relax muscles, but mannitol is not used to accomplish these.

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention? a) Paresthesia in the dermatomes near the wounds b) Temperature of 99.2° F (37.3° C) c) Urine retention or incontinence d) More back pain than the first postoperative day

Urine retention or incontinence Correct Explanation: Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery. An increase in back pain is more common because on the second postoperative day the long-acting local anesthetic, which may have been injected during surgery, will wear off. Although paresthesia is common after surgery, progressive weakness or paralysis may indicate spinal nerve compression. A mild fever is also common after surgery but is considered significant only if the temperature reaches 101° F (38.3° C).

The nurse should inform a client with Ménière's disease that before an attack of the disease, the client may experience: a) a severe headache. b) blurred vision. c) a feeling of inner ear fullness. d) nausea.

a feeling of inner ear fullness. Correct Explanation: Many clients are able to identify an incipient attack of Ménière's disease by a feeling of fullness in the ear that reflects the evolving congestion. Severe headaches are not associated with Ménière's disease. Ménière's disease does not affect vision. Nausea may result after the classic symptom occurs.

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 sweat chloride test. c) a positive edrophonium test. d) Brudzinski's sign.

a positive edrophonium test. Explanation: A positive edrophonium test confirms the diagnosis of myasthenia gravis. After edrophonium administration, most clients with myasthenia gravis show markedly improved muscle tone. Kernig's sign and Brudzinski's sign indicate meningitis. The sweat chloride test is used to confirm cystic fibrosis. (

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will: a) be emotionally stable and display pre-injury personality traits. b) actively participate in the rehabilitation process as appropriate. c) exhibit no further episodes of short-term memory loss. d) be able to return to his construction job in 3 weeks.

actively participate in the rehabilitation process as appropriate. Correct Explanation: Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client

When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for: a) hypertension. b) sensory loss. c) aspiration. d) bladder dysfunction.

aspiration. Correct Explanation: Loss of motor function to the face and throat can cause dysphagia and places the client at risk for aspiration. Bladder dysfunction and hypertension are not associated with myasthenia gravis. Myasthenia affects nerve impulses at the neuromuscular junction, causing loss of motor function; there is no sensory deficit.

For a neurologically injured client, the nurse should assess motor strength by: a) observing spontaneous movements. b) observing the client feed himself or herself. c) asking the client to signal when feeling pressure applied to the feet. d) comparing equality of hand grasps.

comparing equality of hand grasps. Correct Explanation: Comparing equality of hand grasps is a technique used to assess motor strength. The ability to move spontaneously demonstrates motor ability but not strength. Noting that the client can feed himself or herself verifies coordination and motor ability but does not help determine muscle strength. Having the client signal when pressure is applied to the feet tests sensory function.

A nurse is caring for a female client following a motor vehicle accident resulting in paraplegia. The client is ready for discharge to home with her husband, who states, "I'm scared to carry her because I'm afraid I'll either hurt my back or drop her." A nurse identifies a need for discharge teaching of the husband in regard to: a) nutritional changes for the client with paraplegia. b) the importance of monitoring urinary elimination. c) ergonomic principles and body mechanics. d) signs and symptoms of chronic back pain that he should report to his physician.

ergonomic principles and body mechanics. Correct Explanation: The husband's statement indicates a need for teaching in regard to client mobility and transfer techniques. Although urinary elimination, nutrition, and pain are components of care for clients with paraplegia, education about ergonomic principles and body mechanics is most appropriate at this time based on the husband's statement.

The nurse should instruct the client with low back pain to avoid: a) keeping light objects below the level of the elbows when lifting. b) sleeping on the side with legs flexed. c) leaning forward while bending the knees. d) exceeding the prescribed exercise program.

exceeding the prescribed exercise program. Correct Explanation: The client with low back pain should not exceed the prescribed exercises even though they may think, "If this will make me well, double will make me well quicker." When exceeding prescribed exercise programs, the client's muscle may be unconditioned and easily tired, leading to injury and increased pain. To use proper body mechanics when lifting light objects, the client should bring the item close to the center of gravity, which occurs when the object is kept below the level of the elbows. Leaning forward while bending the knees allows for the muscles of the thigh to be used instead of those of the lower back. Sleeping on the side with the legs flexed is appropriate because the spine is kept in a neutral position without twisting or pulling on muscles.

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for: a) expressive aphasia. b) agnosia. c) dyslexia. d) apraxia.

expressive aphasia. Correct Explanation: Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia. Dyslexia, the inability of a person with normal vision to interpret written language, is thought to be due to a central nervous system defect in the ability to organize graphic symbols. Apraxia is the inability to perform purposeful movements in the absence or loss of motor power, sensation, or coordination. Agnosia is the loss of comprehension of auditory, visual, or other sensations despite an intact sensory sphere.

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for: a) expressive aphasia. b) apraxia. c) dyslexia. d) agnosia.

expressive aphasia. Correct Explanation: Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia. Dyslexia, the inability of a person with normal vision to interpret written language, is thought to be due to a central nervous system defect in the ability to organize graphic symbols. Apraxia is the inability to perform purposeful movements in the absence or loss of motor power, sensation, or coordination. Agnosia is the loss of comprehension of auditory, visual, or other sensations despite an intact sensory sphere.

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? a) limiting fluid intake to 1,000 mL/day b) eating a diet high in fiber c) setting a regular time for elimination d) using an elevated toilet seat

limiting fluid intake to 1,000 mL/day Correct Explanation: Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position

The primary nursing goal for a client with myasthenia gravis is to: a) ensure a safe environment. b) maintain respiratory function. c) promote comfort and relieve pain. d) provide psychological support and reassurance.

maintain respiratory function. Correct Explanation: In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure. Providing a safe environment and emotional support are secondary goals. Pain is not commonly associated as a problem of myasthenia gravis.

The primary nursing goal for a client with myasthenia gravis is to: a) provide psychological support and reassurance. b) maintain respiratory function. c) ensure a safe environment. d) promote comfort and relieve pain.

maintain respiratory function. Correct Explanation: In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure. Providing a safe environment and emotional support are secondary goals. Pain is not commonly associated as a problem of myasthenia gravis.

A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately? a) new onset of footdrop b) diffuse, aching sensation in the L4 to L5 area c) pain in the lower back that radiates to the hip d) pain in the lower back when the leg is lifted

new onset of footdrop Explanation: Neurologic symptoms, such as footdrop, or bowel or bladder changes, should be reported to the HCP immediately. When musculoskeletal strain causes back pain, these symptoms may take 4 to 6 weeks to resolve. As an accompanying symptom of acute low back pain, the client may have a diffuse, aching sensation in the L4 to L5 area, pain in the lower back when the leg is lifted, or pain that radiates to the hip.

A client has short-term memory loss. To help the client cope with memory loss, the nurse should: a) ask the client to try harder to remember things. b) tell the client in the morning what activities will be expected to be performed that day. c) place a single-date calendar where the client can view it. d) instruct family members to ignore the behavior.

place a single-date calendar where the client can view it. Correct Explanation: It is not unusual for a client to be disoriented and suffer short-term memory loss after a head injury. Clocks, single-date calendars, and other items to help orient the client should be provided. Frequent reassurance and orientation by the nurse and family members will help the client understand the reason for hospitalization and recognize being in a safe environment. Ignoring the client's behavior would not provide the client with the needed reassurance and assistance. Explanations of activities should be simple and given immediately before the procedure. Telling the client to try harder will increase frustration and cause anxiety.

A client with a ruptured intervertebral disc at L4-5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating: a) postural deformity. b) motor changes. c) alteration of reflexes. d) sensory changes.

postural deformity. Correct Explanation: Standing with a flattened spine slightly tilted forward and slightly flexed to the affected side indicates a postural deformity. Motor changes would include findings such as hypotonia or muscle weakness. Absent or diminished reflexes related to the level of herniation would indicate alteration in reflexes. Sensory changes would include findings such as paresthesia and numbness related to the specific tract of the herniation.

The primary goal in the plan of care for the client after cataract removal surgery is to: a) promote safety at home. b) maintain a darkened environment. c) prevent fluid volume excess. d) increase cardiac output.

promote safety at home. Correct Explanation: Promoting safety is a priority goal for this client. The client's vision will not be clear, and the client may need to wear an eye patch after surgery. Orienting the client to the physical environment, assisting the client during ambulation, and following other safety precautions to reduce the risk of injury are required. Cardiac output and fluid volume excess are unrelated to cataract surgery. Maintaining a darkened environment is neither necessary nor safe.

The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. The nurse should: a) withhold the tube feeding and notify the health care provider (HCP). b) readminister the residual to the client and continue with the feeding. c) delay feeding the client for 1 hour and then recheck the residual. d) dispose of the residual and continue with the feeding.

readminister the residual to the client and continue with the feeding. Explanation: Gastric residuals are checked before administration of enteral feedings to determine whether gastric emptying is delayed. A residual of less than 50% of the previous feeding volume is usually considered acceptable. In this case, the amount is not excessive and the nurse should reinstill the aspirate through the tube and then administer the feeding. If the amount of gastric residual is excessive, the nurse should notify the HCP and withhold the feeding. Disposing of the residual can cause electrolyte and fluid losses

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial? a) psychotherapy b) weekly visits by another person with MS c) regular exercise d) day care for the granddaughter

regular exercise Correct Explanation: An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients.

Which action would not be appropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc? a) starting an IV line at keep-open rate b) checking for previous reports of claustrophobia c) informing the client that the procedure is painless d) taking a thorough history of past surgeries

starting an IV line at keep-open rate Correct Explanation: An IV line is not required for an MRI. If a client has an IV line, it is usually converted to an intermittent infusion device, such as a saline lock, to avoid infiltration during transport of the client and completion of the procedure. When a contrast agent is used, the client is moved out of the cylinder, the contrast material is injected, and the client is moved back in. An MRI scan is painless. Typically the staff positions the client with pillows, blankets, earplugs, and music, to ensure client comfort, before the procedure is started. A history of past surgeries is important, especially if the surgery involved implantation of any metallic devices (e.g., implants, clips, pacemakers). Additionally, the nurse needs to assess for hearing aids, electronic devices, shrapnel, bra hooks, necklaces, jewelry, credit cards, zippers, or any type of metal that the magnet of the MRI unit would attract. Although open MRI units are now available, they are not in widespread use. Therefore, the nurse needs to determine whether the client is claustrophobic because the unit is a closed cylinder in which the client hears pops of noise. A number of clients develop claustrophobia that causes the procedure to be canceled. If the client is claustrophobic, the procedure may need to be rescheduled after an open MRI unit is located or made available.

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for: a) sudden, severe hypertension b) paralytic ileus c) bradycardia d) hot, dry skin

sudden, severe hypertension Correct Explanation: With a cervical injury, the client has sympathetic fibers that can be stimulated to fire reflexively. The firing is cut off from brain control and is both reflexive and massive. It classically produces pounding headache and dangerously elevated blood pressure, "goose bumps," and profuse sweating. Bradycardia, paralytic ileus, and hot, dry skin typically occur during spinal shock, not during autonomic dysreflexia.

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to: a) tap the tendon slowly and softly. b) use the pointed end of the reflex hammer when striking the Achilles tendon. c) support the joint where the tendon is being tested. d) hold the reflex hammer tightly.

support the joint where the tendon is being tested. Explanation: The nurse should support the joint where the tendon is being tested to prevent the attached muscle from contracting. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc

The client asks when to stop taking the eye medication for chronic open-angle glaucoma. The nurse should tell the client: a) to discontinue the eyedrops after 2 months of normal eye examinations. b) to stop using the eyedrops when the vision improves. c) to use the eyedrops only when there are symptoms. d) to use the eye medication for the rest of life.

to use the eye medication for the rest of life. Correct Explanation: To control increased intraocular pressure, the client will need to continue taking eye medications for the rest of life. Intraocular pressure will increase if medications are discontinued. Any loss of vision that the client has suffered will be permanent. Vision loss can occur gradually without any symptoms.

One day after cataract surgery the client is having discomfort from bright light. The nurse should advise the client to: a) dim lights in the house and stay inside for one week. b) attach sun shields to existing eyeglasses when in direct sunlight. c) patch the affected eye when in bright light. d) use sunglasses that wrap around the side of the face when in bright light.

use sunglasses that wrap around the side of the face when in bright light. Correct Explanation: To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently, and bright light will come in on the side of the face. It is not necessary to patch the affected eye

The nurse is discharging a client who had a fish hook embedded in the eye. The fish hook was removed surgically in the emergency department, but the client currently has no vision in that eye. The surgeon has informed the client that a corneal transplant may restore some vision but the surgery cannot be performed for 6 to 8 weeks and only if no infection occurs. A priority in the teaching plan includes: a) verbalizing feelings regarding vision loss. b) washing hands carefully to keep the area clean and decrease risk of infection. c) resting to reduce strain to the eye and promote healing after surgery. d) eating a healthy diet to promote healing and prevent constipation.

washing hands carefully to keep the area clean and decrease risk of infection. Correct Explanation: Infection prevention is the immediate priority for this client in order to promote healing and successful corneal transplant with potential restoration of vision. Rest and a diet rich in nutrients and fiber to prevent straining due to constipation are important considerations as well as allowing the client to discuss feelings regarding vision loss. However, these are currently lower priority than infection prevention.

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply. a) "Drinking fluids at room temperature should reduce pain." b) "If brushing my teeth is too painful, I'll try to rinse my mouth instead." c) "I'll try to chew my food on the unaffected side." d) "I'll eat food that is very hot." e) "I can wash my face with cold water."

• "Drinking fluids at room temperature should reduce pain." • "If brushing my teeth is too painful, I'll try to rinse my mouth instead." • "I'll try to chew my food on the unaffected side." Correct Explanation: Mechanical or thermal stimuli trigger the facial pain of trigeminal neuralgia. Chewing food on the unaffected side and rinsing the mouth rather than brushing teeth reduce mechanical stimulation. Drinking fluids at room temperature reduces thermal stimulation. Eating hot food and washing the face with cold water are likely to trigger pain.

The nurse is caring for a client who is scheduled to undergo a computerized tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information would the nurse include in a preprocedural teaching plan? Select all that apply. a) A contrast dye may be given before the test. b) Throat irritation and facial flushing may occur if contrast dye is used. c) The CT scan is considered an invasive procedure, but not dangerous. d) The test requires standing alone without assistance. e) It is necessary to report any known allergies to iodine or seafood prior to the procedure. f) All medications must be withheld for 12 hours prior to the procedure.

• A contrast dye may be given before the test. • Throat irritation and facial flushing may occur if contrast dye is used. • It is necessary to report any known allergies to iodine or seafood prior to the procedure. Explanation: The nurse would inform the client who is scheduled to undergo a CT scan that a contrast medium may be administered before the procedure and that the dye can cause throat irritation and facial flushing. Because the dye is iodine based, it is essential for the client to report any known allergies to iodine or seafood before testing begins. The CT scan is not invasive or dangerous. The client will need to lie still (not stand) during the procedure and will not be able to take routine medications for 24 hours beforehand

The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. a) Use intermittent catheterization as needed. b) Drink fluids midmorning, midafternoon, and late afternoon. c) Restrict fluids to 1,000 mL/24 hours. d) Drink 400 to 500 mL with each meal. e) Attempt to void at least every 2 hours.

• Drink 400 to 500 mL with each meal. • Drink fluids midmorning, midafternoon, and late afternoon. • Attempt to void at least every 2 hours. • Use intermittent catheterization as needed. Explanation: Maintaining urinary function in a client with neurogenic bladder dysfunction from MS is an important goal. The client should ideally drink 400 to 500 mL with each meal; drink 200 mL midmorning, midafternoon, and late afternoon; and attempt to void at least every 2 hours to prevent infection and stone formation. The client may need to catheterize herself to drain residual urine in the bladder. Restricting fluids during the day will not produce sufficient urine. However, in bladder training for nighttime continence, the client may restrict fluids for 1 to 2 hours before going to bed. The client should drink at least 2,000 mL every 24 hours

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Check all that apply. a) cutting food into large pieces of finger food b) maintaining an upright position while eating c) introducing foods on the unaffected side of the mouth d) keeping distractions to a minimum e) restricting the diet to liquids until swallowing improves

• maintaining an upright position while eating • introducing foods on the unaffected side of the mouth • keeping distractions to a minimum Explanation: A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. Large pieces of food could cause choking; the food should be cut into bite-sized pieces.

A nurse is taking a medication history on a client with multiple sclerosis before administering an initial dose of baclofen. What should the nurse check before administering the drug? Select all that apply. a) blood glucose b) serum creatinine level c) history of muscle spasms d) presence of muscle weakness e) serum potassium level

• presence of muscle weakness • history of muscle spasms • serum creatinine level • blood glucose Explanation: The nurse should ask the client with multiple sclerosis about areas of muscle weakness because baclofen may increase the weakness. The nurse should ask the client about a history of muscle spasms. Baclofen is effective against involuntary spasms resistant to passive movement for clients with multiple sclerosis and paralysis. Baclofen is not effective against the spasticity of cerebral origin, such as with cerebral palsy and Parkinson's disease. The nurse should ask the client about the client's liver and renal function because baclofen is metabolized and excreted by these organs. The nurse should check the laboratory values reflecting the function of the kidneys and liver, which include serum creatinine and blood urea nitrogen levels. The nurse should also check blood glucose levels because baclofen can increase blood glucose. Clients with diabetes taking antidiabetic medication may need to adjust the dosage. Potassium is not affected by the drug, so the nurse does not need to check the serum potassium level.

When caring for a client with myasthenia gravis, the nurse should assess the client for which manifestations of cholinergic crisis? Select all that apply. a) respiratory rate of 6 and irregular b) ptosis c) abdominal cramps d) fasciculation e) increased heart rate f) decreased secretions and saliva

• ptosis • fasciculation • respiratory rate of 6 and irregular Explanation: Cholinergic crisis is caused by overstimulation at the neuromuscular junction due to increased acetylcholine. The crisis affects the muscles that control eye and eyelid movement, causing fasciculation, ptosis (drooping eyelids) and difficulty chewing, talking, and swallowing. The muscles that control breathing and neck and limb movements are also affected, and respirations become slowed. Salivation is increased. The crisis is reversed with atropine