NCLEX neuro

what spinal cord region results in respiratory difficulties

c4

which posturing is worse?

decerebrate - all 4 extremities in rigid extension decorticate - arms flexed inwards on chest

difference bt closed and open skull fracture

dura is torn in open fracture

whats worse - epidural or subdural hematoma

epidural - arterial bleeding, usually happens rapidly (between dura and skull) SURGICAL EMERGENCY subdural - venous bleed, happens slower

3 categories of Glasgow coma scale

eye opening - 4 verbal response - 5 motor - 6

positioning for lumbar puncture

fetal position (back need to be arched) inserted in L3-L4

tonic clonic , absence, myoclonic

tonic clonic - stiff muscles followed by jerking of extremities absence - looks like pt is daydreaming myoclonic - brief jerking or stiffness

infection you can get from LP

meningitis

whats always held when using dye for tests?

metformin - lactic acidosis

what is the normal value for ICP

0-15

sx of meningitis

Headache, fever, neck pain, neck stiffness, photophobia

what numbers are ideal for Glasgow coma

13-15 less than 8 intubate

Is dye used in CT or MRI?

CT - can be with or without MRI - not usually (magnet is used)

earliest sign of ICP

Change in LOC

what does a positive babinski mean?

severe CNS problem (tumor on brain or spinal cord, MS)

A client with psychosis, tells another client, "You are so adorabogalishus." Which form of thought process should the nurse document this client as having? You answered this question Correctly 1. Magical thinking 2. Tangentiality 3. Neologism 4. Perseveration

3. Correct: The psychotic person invents new words, or neologisms, that are meaningless to others but have symbolic meaning to the psychotic person. Remember, do not use the invented word. "Adorabogalishus" is not a real word. 1. Incorrect: With magical thinking, the person believes that their thoughts or behaviors have control over specific situations or people. The client believes that thinking something can make it happen. 2. Incorrect: With tangentiality, the person never really gets to the point of the communication. Unrelated topics are introduced, and the original discussion is lost. The client goes off the topic which can destroy interpersonal communications. 4. Incorrect: The person who exhibits perseveration persistently repeats the same thought, phrase or motor response to different questions. This is associated with brain damage.

signs basal skull fracture

EENT bleeding battles sign (bruising behind ear) raccoons eyes

whats better - MRI or CT?

MRI - more detailed pictures, picks up on problems earlier CT takes pictures in slices

How do we tell CSF from other drainage?

Positive for glucose and the Halo test

pt teaching for seizure meds

abrupt withdrawal can cause seizure toxic side effects - monitor drug levels

what spinal cord injury is fatal

c2 c3

most common s/e from LP

headache will increase is pain when pt sits up tx with bed rest, fluid, pain meds, blood patch (draw blood from arm and inject in spine to form instant seal)

Gillian barre plan of care

keep trach at bedside monitor for respiratory failure (Signs include heart rate that is more than 120 bpm or lower than 70 bpm and respiratory rate of more than 30 bpm) nurse performs passive range of motion (pt too weak)

post procedure for LP

lie flat for 2-3 hours so puncture site seals encourage fluids to replace CSF

cardinal sign of epidural hematoma

lose consciousness, lucid period, coma

who can't have MRI

pacemakers, implanted defibrillators, metal implants, pregnant women (increase in amniotic fluid temp can be harmful to fetus) old tattoos may matter (may contain lead)

partial vs generalized seizures

partial - localized generalized - entire brain

tx of ICP

-maintain o2 and low CO2 (will vasoconstrict and decrease blood flow) -HOB at 30-40, head midline -decrease stimuli (limit suction, space interventions) -DO NOT want hypotension or bradycardia: use dobutamine or norepinephrine -maintain body temp below 100.4: increased temp increases ICP, shivering causes increased ICP Meds: -mannitol - pulls fluid from brain cells -dexamethasone - decreases cerebral edema -antiseizure med -antipyrectic if fever, muscle relaxant if shivering ICP monitor device - watch for infection bacterial travels faster through wet dressing

What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips? You answered this question Correctly 1. Notify the primary healthcare provider 2. Monitor for paresthesia in the fingers and hands 3. Insert an indwelling urinary catheter 4. Assist the client with performing passive range of motion

1. Correct: Symptoms are classic for Guillain-Barre. The possibility of rapid progression and respiratory failure make this a medical emergency. The nurse's priority action is to notify the healthcare provider. 2. Incorrect: The nurse should continue to monitor for paresthesia in the upper body and arms. The first priority in this situation is to notify the primary healthcare provider of the potential life threatening situations. 3. Incorrect: Urinary retention is a possible complication with Guillain-Barre, and the client may require an indwelling urinary catheter, but the immediate priority is to notify the primary healthcare provider. 4. Incorrect: Passive range of motion is performed to prevent complications of immobility, but this is not the priority at this time. The client is presently able to move their extremities. Passive range of motion is not the priority at this time.

normal size of pupils

2-6

The post-operative craniotomy client's urinary output suddenly increases to 325 mL in 30 minutes. Which nursing action takes priority? You answered this question Correctly 1. Check urine specific gravity 2. Measure ICP level 3. Obtain blood pressure 4. Monitor CVP

3. Correct: This is the best answer because we are "worried" this client is going into SHOCK. So.....you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom. 1. Incorrect: Not the priority here. We are worried about shock. 2. Incorrect: We worry about increased ICP, however, an increased UOP indicates possible diabetes insipidus, so shock is likely. 4. Incorrect: If my client is going into shock, the highest priority is to assess the blood pressure. CVP will let us know if the client has FVD, but the BP will let us know if the client is tolerating it.

directions for any angiogram

allergies for shellfish/iodine well hydrated before test (promote excretion of dye) NPO for 4-6 hrs get baseline vitals, pulses, and LOC (esp if cerebral angiogram) will be awake - teach pt about hot shot, local anesthetic, etc post procedure - bed rest 4-6 hrs, bed flat watch for bleeding at fem site (may need sand bag) encourage fluid intake

becks triad vs cushings triad

becks - cardiac tamponade narrow pulse pressure w/ hypotension muffled heart sounds JVD cushings - icp widened pulse pressure w/ hypertension slow bounding pulse irregular respirations (cheyne stokes)

2 complications of ICP

brain herniation DI/SIADH

tx for epidural hematoma

burr holes to decrease ICP craniotomy

what spinal cord region causes quadriplegia

cervical

pre-procedure teaching for EEG

hold sedatives, caffeine, and anti seizure meds for 24-48 hrs before does not need to be NPO (will drop BG and effect electric reactions) tell pt that electrodes are attached to head if pt is unconscious, might stimulate a pain response or noxious stimuli (bright light) to stimulate brain wave

difference b/t simple and complex partial seizures

simple - no loss of consciousness complex - loss of consciousness only manifestation is aura

autonomic dysreflexia happens above what injury

t6

The client is experiencing autonomic dysreflexia. What is the first action by the nurse? You answered this question Correctly 1. Place in high Fowler's position 2. Find and remove the trigger source 3. Notify the primary healthcare provider 4. Assess for fecal impaction

1. Correct: This first action provides some immediate relief to decrease the blood pressure while you are preparing for other interventions. This is one thing the nurse can do immediately to help fix the problem. 2. Incorrect: Later you will look for bladder or bowel distention which is a common precipitating cause of autonomic dysreflexia. 3. Incorrect: The primary healthcare provider will be notified after the nurse intervenes quickly with appropriate nursing measures. 4. Incorrect: Sit client up is the priority and then look for causes.

The homecare nurse is instructing the family of a client recently diagnosed with Parkinson's disease about potential neurologic changes. During the discussion, what signs should the nurse include? You answered this question Correctly 1. Unsteady gait 2. Muscle rigidity 3. Hyperactive reflexes 4. Bradykinesia (slowed movements) 5. Expressive aphasia

1., 2 & 4. Correct: Parkinson's disease is a debilitating, progressive neurological disorder of unknown cause. The most classic symptoms include unsteady gait secondary to increasing muscle rigidity and bradykinesia, plus difficulty with purposeful movement. These symptoms worsen over time and are often accompanied by tremors in the extremities at rest. 3. Incorrect: Reflexes in clients with Parkinson's disease become progressively slowed, not hyperactive. Because this disorder affects the midbrain, and ultimately the connection of the basal ganglia, deep tendon reflexes decrease over the course of the disease. Hyperactive reflexes are associated with other neurologic disorders such as multiple sclerosis. 5. Incorrect: Expressive aphasia is associated with brain trauma or cerebral vascular accident (CVA) and prevents the client from verbalizing appropriate or desired terminology. In Parkinson's disease, the client's speech volume becomes too low and very monotone. Also, because of facial muscle rigidity, there is great difficulty articulating words enough to be clearly understood.

A nurse is assigned to care for a client diagnosed with obsessive compulsive disorder. Which interventions should be part of the treatment plan? You answered this question Incorrectly 1. Provide a structured schedule 2. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants should be considered 3. Discuss why the ritual is harmful for the client 4. Allow as much time as necessary for the ritual 5. Encourage relaxation techniques

1., 2. & 5. Correct: The nurse must provide a structured schedule. This client's anxiety comes from an unconscious conflict or anxiety and a structured schedule helps this anxiety. SSRIs and tricyclic antidepressants may help this disorder. Encourage relaxation techniques-the anxiety with this disorder comes from an unconscious conflict or anxiety. Encouraging relaxation techniques can provide another coping mechanism. 3. Incorrect: Obsession is a recurrent thought and a compulsion is a recurrent act. They do not know why they need the ritual, just that it relieves their anxiety. They cannot stop. Explaining why the ritual is harmful is verbalizing disapproval and they feel bad enough as it is. They can't stop. 4. Incorrect: Allow as much time as necessary for the ritual. You do give them time in the schedule for the ritual, however, you start decreasing the amount of time that you give them. You should never take the ritual without replacing it with another coping mechanism such as anxiety reduction techniques.

The nurse is preparing discharge teaching for a client diagnosed with peripheral vascular disease. Which teaching points should the nurse include about foot and leg care? You answered this question Correctly 1. Wear soft cotton socks 2. Avoid whirlpools 3. Rub feet dry 4. Wash feet every other day 5. Clear pathways in house

1., 2. & 5. Correct: These are correct teaching points to avoid injury to feet. 3. Incorrect: Feet should be patted rather than rubbed dry to prevent tissue injury. 4. Incorrect: Feet should be washed and dried daily.

A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take? You answered this question Correctly 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. 4. Encourage the client to walk. 5. Apply a heating pad to the feet. 6. Massage the frozen digits.

1., 2., & 3. Correct: Wet clothing is removed to eliminate continued exposure to the cold and allow the warming process to begin. Swelling is common so anything, such as clothing or jewelry that could cause constriction to blood flow should be removed. A controlled and rapid re-warming process is accomplished using a continuous flow of warm water until flushing is noted in the affected areas. Antiseptics or antibiotics are often used, and each digit is wrapped individually with sterile gauze (not constricting) to minimize the risk of infection and assist in the warming process. The core should be re-warmed first to prevent "afterdrop" which is a further drop in core temperature caused by cold peripheral blood returning to the central circulation. 4. Incorrect: Movement of frostbitten areas can cause ice crystals to form in the tissue and cause further damage. In addition, lack of sensation places the client at risk for falls or other injury. 5. Incorrect: External heat such as heating pads, fireplaces, etc. should not be used because burns are more likely to result due to the presence of decreased sensation in the affected areas. 6. Incorrect: Initial rubbing or massage of the frostbitten digits is an absolute contraindication as it can cause further tissue damage. Gentle handling is required to prevent stimulation of the cold myocardium.

A nurse is assigned a 4 year old client who is one day post VP shunt placement. Client assessment shows a fever of 104º F (40ºC), vomiting, irritability, headache and dilated scalp veins. What interventions should the nurse take? You answered this question Correctly 1. Notify the surgeon 2. Monitor for seizures 3. Administer antipyretic 4. Monitor potassium level 5. Increase IV fluids

1., 2., & 3. Correct: What are the hints? Elevated temp, vomiting, irritability, headache, dilated scalp veins. All symptoms of increased ICP!!! What is the problem: The VP shunt has malfunctioned and there's a possible infection because they have developed a high temp. We need to decrease ICP, so call the surgeon to fix the malfunctioning shunt. Monitor for seizures, and treat the fever. Remember your adult neuro lecture all of that content we learned applies here. A peds specific intervention would be to measure head circumference, although that intervention is not applicable here. 4. Incorrect: Do we really care what their potassium level is when we have increased ICP??? 5. Incorrect: And y'all increasing IV fluids is just wrong with increased ICP! I'm scared if you picked this!!

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? You answered this question Incorrectly 1. Elevate HOB 30 degrees 2. Pad side rails 3. Provide sponge bath if temperature greater than 101°F (38.3°C) 4. Initiate airborne isolation precautions 5. Darken room

1., 2., 3. & 5. Correct: An acute onset of fever, headache, stiff neck, n/v, and mental status changes are consistent with bacterial meningitis. Elevate the head of the bed to promote comfort and decrease intracranial pressure. The client is at an increased risk for seizures, and the nurse should implement seizure precautions which include padding the side rails. A sponge bath is an independent nursing intervention appropriate for a fever greater than 101°F (38.3°C). Darkening the room is also a comfort measure as this client will have photophobia. 4. Incorrect: Droplet precautions should be initiated for the first 24 hours of antimicrobial therapy.

A client has been admitted to the telemetry unit with a diagnosis of a cerebral vascular accident. What should the nurse assess to determine the client's risk for aspiration? You answered this question Incorrectly 1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex 5. Ability to follow commands

1., 2., 3., & 4. Correct: Assessing the ability of a client to swallow is something the nurse can and should do. A small amount of water should be given to the client as the nurse observes for coughing or gurgling. If the nurse suspects a client is having difficulty safely swallowing, further assessment by a speech and language therapist is recommended. To test for a gag reflex use a tongue depressor. Ask the client to open the mouth and look at their throat with a penlight. If the uvula and pharynx rise as the client says "aaahh" then the gag reflex is intact. If it does not rise, touch the back of the throat at the soft palate and watch for the rise in the pharynx in a gag response, If intact,the client should not be at risk for aspiration with eating. A client with a decrease level of consciousness is always at risk for dysphagia and aspiration. A cough reflex is assessed by administering a small sip of water and observing for a cough. if the client coughs, feeding should be withheld until further testing can be performed. 5. Incorrect: Assessing ability to follow commands does not identify a problem with swallowing. It does not provide a great deal of information about cognitive function. The other tests provide more information specific to aspiration.

The client's EEG revealed epileptiform abnormalities predictive of seizure activity and was started on valproic acid 500 mg PO twice a day. What nursing interventions should the nurse include in this client's plan of care? You answered this question Incorrectly 1. Instruct client to report insomnia 2. Assess for Grey Turner's sign 3. Monitor ALT and AST 4. Teach client not to discontinue medication abruptly 5. Instruct client to take acetaminophen for mild pain

1., 2., 3., & 4. Correct: Insomnia is a side effect of this medication.What is Grey Turner's sign a symptom of? Did you say pancreatitis? I hope so! And the development of pancreatitis is a risk associated with the administration of valproic acid, so you need to be monitoring this client for S&S of pancreatitis. ALT and AST are your liver enzymes and you better be watching those because valproic acid can cause serious, even fatal hepatotoxicity. Now #4, we know this is true. Clients should never discontinue anti-seizure meds abruptly. 5. Incorrect: False because acetaminophen is hepatotoxic! Let's pick another pain reliever since we know valproic acid can be hepatotoxic.

What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? You answered this question Incorrectly 1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform 5. Pyrexia 6. Purulent drainage

1., 2., 3., & 4. Correct: These are signs of cannula displacement. Observe for signs of cannula displacement into the tissues which will be swelling, bleeding, lack of a normal arterial waveform, fluid leakage, blanching, and pain or discomfort. 5. Incorrect. This is a sign of infection rather than cannula displacement. Signs of infection include pain, redness, purulent drainage, and fever. 6. Incorrect. This is a sign of infection rather than cannula displacement.Signs of infection include pain, redness, purulent drainage, and fever.

What information should a community health nurse include while planning an educational program on prevention of deep vein thrombus formation for a group of people who attend a senior citizens center? You answered this question Correctly 1. Exercise legs by raising and lowering heels while toes are on floor when traveling by plane. 2. Stop smoking 3. Lose weight 4. Stop every 4 hours to walk when traveling by car 5. Exercise daily

1., 2., 3., & 5. Correct: If on a plane, try to stand or walk occasionally. If unable to do that, at least try to exercise lower legs. Try raising and lowering your heels while keeping your toes on the floor, then raising your toes while your heels are on the floor. Make lifestyle changes. Lose weight and quit smoking. Obesity and smoking increase your risk of deep vein thrombosis. Get regular exercise. Exercise lowers a person's risk of blood clots, which is especially important for people who have to sit a lot or travel frequently, 4. Incorrect: If traveling long distances by car, stop every hour or so and walk around.

The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? You answered this question Incorrectly 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

1., 2., 4., 5., & 6. Correct: These are all modifiable risk factors that can be managed through lifestyle changes or medical treatment. 3. Incorrect: Hispanics, African Americans, Native Americans, and Asian Americans have a higher incidence of strokes than whites. You cannot change your race or ethnicity so this is a non-modifiable risk factor for stroke.

The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider? You answered this question Correctly 1. Difficulty waking up 2. Headache (3/10 on the pain scale) 3. Blurry vision 4. Achy feeling all over 5. Vomiting

1., 3. & 5. Correct: Increased intracranial pressure (ICP) is a result of increased pressure around the brain or blood in the brain. These are signs of increasing intracranial pressure (post-concussion syndrome). This is a medical emergency, and the PHP should be notified immediately. 2. Incorrect: A headache of 3/10 on the pain scale does not warrant notifying the primary healthcare provider. The primary healthcare provider should be notified if the pain intensity increases. 4. Incorrect: This is not related. This is not a symptom of increased ICP.

What nursing interventions should the nurse initiate in a client who experiences sundowning? You answered this question Incorrectly 1. Limit naps. 2. Encourage TV watching in the evening. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 5. Leave the lights on at night. 6. Maintain a routine.

1., 3., 4., & 6. Correct: Sundowning occurs when the client becomes more confused and agitated in the late afternoon or evening. Behaviors commonly seen include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. Limit naps because too much daytime napping may interfere with sleeping at night. Light therapy may reduce agitation and confusion so open the blinds. Caregivers should remain calm and avoid confrontation. Routine helps the client feel secure. 2. Incorrect: Watching television for this client may lead to restlessness, agitation, and confusion. Calming and more restful activities are better for the evening. 5. Incorrect: Lights should be on during the day but turned off at night (except for low lighting or nightlights so the client can see).

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? You answered this question Correctly 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1., 3., 4., & 6. Correct: This client will have progressive weakness and paralysis. Contractures and pressure ulcers need to be prevented through ROM exercises and frequent turning. Muscle spasms and pain can be relieved by therapeutic massage, imagery, diversion, and pain medication. 2. Incorrect: The client will need to be repositioned every 2 hours to prevent pressure sores and pneumonia and atelectasis. Elevate the head of the bed to help with lung expansion. Prone will interfere with lung expansion ability. 5. Incorrect: Encourage small, but frequent meals that are both well-balanced and nourishing.

The nurse is caring for a client with increased intracranial pressure (ICP). Which actions would increase the client's ICP? You answered this question Incorrectly 1. Using restraints 2. Elevating head 3. Performing Valsalva 4. Blowing nose 5. Keeping client supine 6. Suctioning

1., 3., 4., 5 & 6. Correct: All of these actions will cause increased pressure in the cerebral vascular system due to the vagal response that occurs through the valsalva, blowing nose, and suctioning. Restraints can result in the client fighting against restraints to cause an increase in pressure in the cerebral vascular system. With the client lying supine, more fluid is in the cerebral spinal space due to decreased drainage. 2. Incorrect: HOB should be raised at least 30 degrees. This decreases ICP.

What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland? You answered this question Correctly 1. Monitor intake and output. 2. Restrict fluids to no more than 1500 ml/day. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.

1., 3., 4., 5., & 6. Correct: Removal of the pituitary gland can lead to diabetes insipidus (DI) as a result of the reduced production of antidiuretic hormone (ADH). The nurse should monitor I & O closely and watch for an increase in output which would indicate diuresis as part of DI. Daily weights are an important part of monitoring the client's fluid status. Monitoring the urine specific gravity is another good way of assessing the fluid status because, as the urinary output increases, the client's urine is becoming more dilute, which would result in a lower urine specific gravity. If the client's serum volume is decreasing from the excessive diuresis, the client can go into shock. The nurse should monitor for early signs of changes in the level of consciousness. To avoid disrupting the surgical site, the client should not blow the nose forcefully for at least one week post-op. 2. Incorrect: If the client is lacking ADH, the client may begin losing large amounts of fluid volume. Therefore, the fluid intake would need to be increased (not decreased) to avoid dehydration and shock.

Which interventions should the nurse include in the plan of care for a client who has been admitted with a head injury? You answered this question Incorrectly 1. Pad side rails. 2. Place hips in flexed position for 15 minutes every 4 hours. 3. Elevate head of bed 35 degrees. 4. Maintain neck in neutral position. 5. Cluster nursing activities. 6. Maintain a quiet environment.

1., 3., 4., and 6. Correct: The client with a head injury is at risk for seizures. Padding the side rails is a safety precaution. Elevate the HOB 30-45 degrees to facilitate venous drainage and reduce ICP. Maintain the client's head midline to facilitate blood flow. A quiet environment is necessary to keep the client calm. An increase in environmental stimuli can increase ICP. 2. Incorrect: Do not allow pronounced neck or hip flexion as ICP will increase. Maintain HOB at 30-45 degrees and body in neutral position to avoid an increase in ICP. 5. Incorrect: Clustering nursing activities will increase ICP. Activities should be spaced out. Remember, the client needs a quiet environment.

The nurse is planning care for a client admitted with a diagnosis of new onset myasthenia gravis. Which nursing interventions should the nurse include in order to decrease the risk of aspiration? You answered this question Incorrectly 1. Provide thin liquids such as water with meals. 2. Offer small bites of food. 3. Allow client to rest between each bite of food. 4. Offer small meals in the morning and larger meals in the evening. 5. Position client upright with head tilted slightly back when eating. 6. Provide meals 30 minutes before administration of cholinesterase inhibitor medication.

2,3 Because muscle fatigue impairs chewing and swallowing, the nursing interventions should facilitate maintaining nutritional status and decreasing the risk for aspiration. Allow the client to rest before eating and drinking. Provide foods that are soft, tender, and not sticky and do not require a lot of chewing. Provide highly viscous foods and thickened liquids that are easy to chew and swallow. Offer the client small bites and instruct to chew well, eat slowly, swallow after each bite, and swallow frequently. Allow the client to rest while chewing and in between bites to restore strength. Allow the client to take small sips of liquids. Provide frequent, small meals that include high calorie and high protein foods. Offer large meals in the morning and small meals in the evening. Offer softer consistencies and moisten dry food. Position the client upright with head slightly forward when eating and drinking, using compensatory maneuvers (chin tuck, head turn) as necessary. Discourage talking and eating at the same time and avoid distractions while eating. Review principles of nutrition and basic food groups so clients can select foods that provide a balanced diet. Consult with a dietitian to determine nutritious food choices. Consult with a speech pathologist to determine the safest, most effective swallowing technique. Provide meals 30 minutes after administration of cholinesterase inhibitor so the medication has time to work and client is eating during optimal strength period.

A client has been admitted with a stroke on the right side of the brain. What clinical manifestations does the nurse expect to find when assessing this client? You answered this question Incorrectly 1. Right sided hemiplegia 2. Impaired judgment 3. Depression 4. Impaired language comprehension 5. Impulsiveness 6. Impaired speech

2,5

What interventions should the nurse include in the care plan of a client admitted with Guillain-Barre syndrome? You answered this question Incorrectly 1. Assess for descending paralysis. 2. Keep a sterile tracheostomy at the bedside. 3. Monitor for heart rate above 120/min. 4. Maintain in side-lying, supine position. 5. Have client perform active range of motion (ROM) every 2 hours while awake.

2. & 3. Correct: This client is at risk for respiratory paralysis as the disease progresses. An emergency tracheostomy may need to be performed so the nurse should watch out for imminent signs of respiratory failure. Signs include heart rate that is more than 120 bpm or lower than 70 bpm and respiratory rate of more than 30 bpm. The nurse should assess for signs of respiratory distress and prepare for intubation if needed. 1. Incorrect: Ascending paralysis should be assessed for with this disease. Paralysis begins in the lower extremities and moves upward. 4. Incorrect: The client should be assisted to a position with head of bed elevated for full chest excursion. 5. Incorrect: The nurse should perform passive range of motion exercises. Active exercise should be avoided during the acute phase as the client is easily fatigued and muscles are weak. Passive ROM stimulates circulation, improves muscle tone and increases joint mobilization.

The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse? You answered this question Incorrectly 1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used. 2. Benztropine is given to treat the side effects produced by the chlorpromazine. 3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine. 4. Chlorpromazine is used for psychosis and benztropine is used for preventing agranulocytosis.

2. Correct: Benztropine is used to treat parkinsonism of various causes and drug-induced extrapyramidal reactions seen with chlorpromazine, which is an antipsychotic agent. Extrapyramidal symptoms are neurologic disturbances in the area of the brain that controls motor coordination. This disruption can cause symptoms that mimic Parkinson's disease, including stiffness, rigidity, tremor, drooling and the classic "mask like" facial expression. These symptoms can be treated and are reversible using such medications as benztropine. 1. Incorrect: Chlorpromazine does not potentiate the effects of benztropine, so dosage regulation is not appropriate. 3 Incorrect: Chlorpromazine can be used for severe hiccups, but the hiccups are not the result of using benztropine. Chlorpromazine is also used for psychosis in the schizophrenic client. 4. Incorrect: Benztropine is not used to prevent agranulocytosis.

During a physical assessment of a client who was started on haloperidol 5 days ago, the nurse notes restlessness, muscle weakness, drooling, and a shuffling gait. What should be the nurse's first action? You answered this question Incorrectly 1. Hold the next haloperidol dose. 2. Administer the prn benztropine mesylate. 3. Notify the primary healthcare provider to discontinue the haloperidol. 4. Draw a blood sample for drug level.

2. Correct: Benztropine mesylate is an anticholinergic that counteracts the extrapyramidal symptoms (EPS) seen with the use of haloperidol. 1. Incorrect: Holding a single dose of haloperidol does not correct the extrapyramidal symptoms. 3. Incorrect: The primary healthcare provider has prescribed benztropine mesylate to combat the side effects of the haloperidol. There is no need to notify the primary healthcare provider, which will delay treatment. 4. Incorrect: The client is showing extrapyramidal symptoms associated with haloperidol therapy. Benztropine mesylate is an anticholinergic agent that can be used to treat the extrapyramidal effects that may be seen as a side effect of haloperidol therapy.

The nurse is caring for a client who is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen? You answered this question Incorrectly 1. I must only use the drops in the eye with the increased pressure. 2. My eyes may be different colors, so I will use the drops in both eyes. 3. I must be careful not to overmedicate even if it is just an eye drop. 4. The eyelashes in the eye with the higher pressure may get longer.

2. Correct: The color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. Prostaglandins cause increased permeability in the sclera to aqueous fluid. So, as the prostaglandin agonist increases this activity, the outflow of aqueous fluid increases and the ocular pressure decreases. Administering the drops in the unaffected eye may result in a subnormal intraocular pressure. 1. Incorrect: This comment shows adequate understanding. The client should only treat the eye with the increased pressure. 3. Incorrect: This comment demonstrates that the client does understand the treatment regimen. Overmedicating the affected eye could reduce the intraocular pressure too much. 4. Incorrect: This comment shows understanding. The lashes in the eye being treated will lengthen as opposed to the untreated eye. The changes of the eyelashes (increased length, thickness, pigmentation and number of lashes) are typical with these eye drops and are viewed as a benefit by many clients.

The client with bi-polar disorder is parading around the common areas of the psychiatric unit in a sexually suggestive manner. The client then sits on the lap of one of the young male clients. What should the nurse do? You answered this question Incorrectly 1. Tell the client that the behavior is inappropriate. 2. Accompany the client to the TV room on the unit. 3. Allow the male client to handle the situation. 4. Continue with the unit routine.

2. Correct: This behavior must be interrupted, as the rights of other clients are being jeopardized. The other clients are being exploited by the manic client. Stop the behavior by going with them to another area. Many people with bipolar disorder don't recognize the extreme changes in their moods and the effects these changes have on their lives and others. You must stop them and remove them from the situation. 1. Incorrect: This client is not able to make accurate decisions in this current state, so telling the client that this behavior is inappropriate is not likely to stop it. Hypersexual behavior is often a warning sign of a manic episode. Evaluate the clients medications because the mood stabilizing medications like lithium or valprate (Depakote®​) should prevent these symptoms. 3. Incorrect: The male client has a right to a safe care environment. He should not be exploited by staff or clients. Asking a fellow client to handle an appropriate situation will never be right on the NCLEX. 4. Incorrect: The behavior must be interrupted in order to maintain the rights of other clients and to maintain the dignity of the client who is in a manic state. Ignoring the symptoms and the disruption will not fix the problem. As a nurse you always want to fix the problem.

A client is diagnosed with new onset grand mal seizures. Which nursing interventions should the nurse implement for this client? You answered this question Incorrectly 1. Have an unlicensed assisitve personnel stay with the client. 2. Pad the side rails with blankets. 3. Place the bed in low position. 4. Keep a padded tongue blade at the bedside. 5. Instruct client to call for help when ambulating.

2., 3., & 5. Correct: During a seizure these interventions will help to protect the client from injury. The client may strike the side rails. The bed should be placed in the low position in case the client falls out of the bed. The client would need assistance to the floor if a seizure starts while ambulating. 1. Incorrect: It is not necessary to have someone stay with this client at all times. Place a call light within reach, put the client close to the nurses' station, and pad the side rails. Have the client call for assistance to bathroom. Maintain bed rest until seizures are controlled or ambulate the client with assistance to protect from injury. 4. Incorrect: Do not place a padded tongue blade in a client's mouth during a seizure. The padded tongue blade could cause injury.

A client who has Parkinson's disease has a new prescription for benztropine. What should the nurse include when teaching the client and spouse about this medication? You answered this question Correctly 1. This medication blocks dopamine in the brain to decrease tremors and muscle stiffness. 2. Notify your primary healthcare provider if you develop urinary retention. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 4. No lab tests are needed while taking this medication. 5. Sit up

2., 3., & 5. Correct: Urinary retention is a side effect of benztropine. Benztropine can reduce the ability to sweat and cause the body to overheat. Do not become overheated in hot weather or while you are being active because heatstroke may occur. Benztropine may cause dizziness, lightheadedness, or fainting. Alcohol, hot weather, exercise, or fever may increase these effects. To prevent these negative effects, sit up or stand slowly, especially in the morning. Sit or lie down at the first sign of any of these effects. 1. Incorrect: Benztropine is an anticholinergic. It works by decreasing the effects of acetylcholine, a chemical in the brain. This results in decreased tremors or muscle stiffness, and helps improve walking ability for clients with Parkinson's disease. 4. Incorrect: Lab tests, including liver function, kidney function, lung function, blood pressure, fasting blood glucose, and blood cholesterol, may be performed while using benztropine. These tests may be used to monitor the client's condition or check for side effects.

A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate? You answered this question Incorrectly 1. Abstract reasoning 2. Waxy flexibility 3. Grandiose delusions 4. Anxiety 5. Agitated behavior

2., 3., 4. & 5. Correct: Waxy flexibility describes a condition in which the client allows body parts to be placed in bizarre or uncomfortable positions for long periods of time. Delusions of grandiosity like believing they are a famous person or religious figure is a false fixed belief experienced by the client. If the client is in the acute phase of schizophrenia, the person may be overwhelmed by anxiety and is not able to distinguish thoughts from reality. It is thought that delusions may develop to cope with the anxiety. Agitated behavior like running about and going from one location to another can lead to exhaustion in this client. 1. Incorrect: This client has concrete thinking which implies over emphasis on specific details and an impairment in the ability to use abstract concepts. For example, during the nursing history you may ask the client what brought them to the hospital and the answer will be "a cab"

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? You answered this question Correctly 1. Anti-embolic stockings 2. Smoking cessation 3. Moderate exercise 4. Application of heat 5. Low cholesterol diet 6. Decrease blood pressure

2., 3., 5. & 6. Correct: Senior clients are at increased risk for peripheral artery disease for a variety of reasons, though many erroneously believe that this process is an unavoidable part of the aging process. Educating clients on preventative activities will help reduce incidence of atherosclerosis and improved mobility along with quality of life. Smoking is a major risk factor in developing PAD by contributing to arterial constriction. Clients can increase collateral circulation with a moderate exercise program of at least 30 minutes three times a week. A low cholesterol, heart healthy diet with more fruits and vegetables helps reduce cholesterol while decreasing blood pressure, both important goals towards controlling PAD. 1. Incorrect: Increasing arterial blood flow is important in the prevention or management of peripheral artery disease; however, anti-embolic stockings are designed to improve venous return in clients with decreased mobility. The use of these stockings would actually hinder arterial flow in lower extremities. 4. Incorrect: Clients with PAD often complain of cold extremities secondary to decreased arterial blood flow. But the application of heat such as use of a heating pad is unsafe and is always contraindicated in the elderly with PAD. Inability to sense temperature extremes may result in serious burns to lower extremities. Additionally, clients with PAD do not heal as well from injuries or wounds.

A client is being discharged with halo traction. What should the nurse teach about home care of this traction? You answered this question Correctly 1. Showering is permitted. 2. Apply baby powder under the halo vest to prevent irritation. 3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique. 5. Driving is allowed after discharge.

3. & 4. Correct: Never pull on any part of the halo traction. It can damage or loosen the traction. Pin care is done to prevent infection. Clean around pins at least twice daily with sterile q-tip applicator. Use a new sterile q-tip for each pin site to decrease contamination from one pin site to another. Do not use ointments or antiseptics unless prescribed. 1. Incorrect: Client should never attempt a shower since there is no reliable way to keep vest liner dry. Take sponge baths or sit in a bathtub with about 2-3 inches of water. Use towels or plastic to keep vest from getting wet. 2. Incorrect: Do not use soaps, creams, lotions or powders beneath the vest as these may irritate the skin. 5. Incorrect: Absolutely no operating a motor vehicle until the primary healthcare provider allows this activity: field of vision and movement is narrowed and/or diminished. The client is an impaired driver and could cause an accident.

Donepezil has been prescribed to a client with cognitive impairment. Which statement by the family member indicates understanding of the nurse's instructions on this medication? You answered this question Correctly 1. This medicine will control agitation and aggression. 2. This medication should be given at bedtime since it is for insomnia. 3. Notify the primary healthcare provider if the client is vomiting coffee ground material. 4. This drug is given as needed for confusion.

3. Correct: A rare but very serious side effect that can occur: black stools, vomit that looks like coffee grounds, severe stomach/abdominal pain. Notify the primary healthcare provider immediately. 1. Incorrect: An antipsychotic medication such as risperidone is used for agitation, aggression, hallucinations, thought disturbances, and wandering. Donepezil helps to decrease the symptoms of dementia (impairment of memory, judgment, abstract thinking and personality changes) in client's with Alzheimer disease. 2. Incorrect: Donepezil should be given in the evening just before bedtime, however, it is not for insomnia. Sedative/hypnotics such as zolpidem and temzaepam are given for insomnia. 4. Incorrect: Donepezil should be given regularly in order to get the most benefit from it. Do not stop taking it or increase the dosage unless the primary healthcare provider changes the dose. It may take a few weeks before the full benefit of this drug takes effect.

A client admitted to the hospital following a fall has a history of Alzheimer's disease with apraxia. The nurse knows the client will need priority assistance with what activity? You answered this question Incorrectly 1. Ambulating to the bathroom. 2. Understanding instructions. 3. Using utensils at mealtime. 4. Identifying objects in room.

3. Correct: Apraxia is a motor disorder of voluntary movements in which the individual can no longer execute purposeful activity, even though there is adequate mobility, strength, and coordination. This loss of ability to carry out previously learned movements could occur secondary to brain injury or a disease process such as Alzheimer's disease. The client has the ability to pick up utensils but is unable to use them correctly, which may affect the client's nutritional status. 1. Incorrect: Apraxia does not affect the ability to ambulate to the bathroom, although the client may not be able to follow cleanliness procedures once in the bathroom. However, there is another activity is of more concern. 2. Incorrect: The ability to understand is not affected by apraxia, which is a disorder in which the client loses the ability to perform purposeful movement. The client is still able to comprehend instructions at this point. There is another situation in which the client will need assistance. 4. Incorrect: The client is still able to identify objects in the environment; however, the diagnosis of apraxia indicates the client cannot use previously known objects correctly. Because of this situation, there is another area in which assisting the client is of more importance.

A client with the diagnosis of mild anxiety asks the nurse why the primary healthcare provider switched medications from lorazepam to buspirone. What should the nurse tell the client? You answered this question Incorrectly 1. "Lorazepam takes longer to start working than buspirone so the primary healthcare provider decided to switch medications." 2. "Buspirone can be stopped quickly if neccessary." 3. "Buspirone does not depress the central nervous system like lorazepam does, so you should not have as much sedation." 4. "You need to ask your primary healthcare provider why the medication was changed from lorazepam to buspirone."

3. Correct: Buspirone does not depress the CNS system and is believed to produce the desired effects through interaction with serotonin, dopamine, and other neurotransmitter receptors. 1. Incorrect: Buspirone takes 1-2 weeks to take effect and can take up to 4-6 weeks to achieve full clinical benefits. Lorazepam is a benzodiazepine and begins to work within a few hours to 1-2 days. 2. Incorrect: The client should not stop taking any antianxiety medications abruptly. Serious withdrawal symptoms can occur: depression, insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, delirium. 4. Incorrect: The nurse should be able to discuss medication administration with the primary healthcare provider.

A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client? You answered this question Incorrectly 1. Physical therapy will be needed to maintain muscle tone of the face. 2. Massage the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Acupuncture may provide grat improvement in symptoms.

3. Correct: Even though all are educational points that need to be provided to the client, this is the most important point. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close. 1. Incorrect: Physical therapy will be needed, however care to prevent eye injury takes priority. 2. Incorrect: This can be done once the client's facial sensitivity to touch decreases and the client can tolerate touching the face. Preventing eye injury takes priority. 4. Incorrect: Acupuncture may provide a potential small improvement in function. The priority however, is protection of the eye.

A client diagnosed with a hemorrhagic stroke is being transferred to the medical unit from the intensive care unit. Which nursing intervention should the nurse initially implement? You answered this question Correctly 1. Administer an osmotic diuretic. 2. Complete a neurological assessment. 3. Maintain the head of the bed at 30 degrees. 4. Instruct the client to take a stool softener daily.

3. Correct: Hemorrhagic strokes are the result of ruptured vessel bleeding in the cranial cavity. This action will result in increased intracranial pressure (ICP). ICP can cause a decrease in the brain's metabolism and hypoxia of the brain tissue. The head of the bed should be elevated to decrease the increased intracranial pressure which can reduce damage to the brain. The intervention of raising the head of the bed to 25 -30 degrees is directly related to a decrease in ICP. 1. Incorrect: An osmotic diuretic is administered to increase the osmotic effect on the kidneys which will decrease ICP. An osmotic diuretic is initiated during the acute care protocol for a stroke. 2. Incorrect: A neurological assessment would be done upon admission to the medical unit. But maintaining the head of the bed at 30 degrees is the initial action. 4. Incorrect: The readiness of the client to learn should be evaluated prior to initiating teaching. Due the client's immediate transfer from ICU, this is not the apparent time to begin to the initiate client teaching. Ways to avoid straining during a bowel movement instruction is not the priority nursing intervention.

A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down to eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? You answered this question Correctly 1. Carrots and apples 2. Donuts 3. Pepperoni pizza sticks 4. Strawberry pastry

3. Correct: High protein, high calorie, nutritious finger foods are required when the client will not sit down to eat. This client needs food they can eat "on the go" because they are burning more calories in this phase of bipolar disorder. 1. Incorrect: Although nutritious, these foods are not high calorie or high protein. 2. Incorrect: Donuts are high in calories but do not have high nutritional valve. 4. Incorrect: Pasties are also high in calories but do not have high nutritional valve. They are also not very easy to eat "on the go"

The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client? You answered this question Correctly 1. Orthopneic 2. Dorsal recumbent 3. Sims' 4. Reverse trendelenburg

3. Correct: Sim's is a semi prone position where the client is halfway between lateral and prone positions. Often used for enemas or other examinations of the perianal area. Sim's is used for unconscious client's because it facilitates drainage from the mouth and prevents aspiration. 1. Incorrect: Orthopneic position places the client in a sitting position with arms resting on an overbed table. It allows maximum expansion of the chest. This would not be a safe position for an unresponsive client. 2. Incorrect: Dorsal recumbent is a back lying position where the shoulders are slightly elevated on pillows. it is used after surgeries and anesthetics. 4. Incorrect: Reverse trendelenburg is where the body the body is completely straight but the head is elevated and the feet are down. This position helps with gastroesophageal reflux disease, snoring, and with some surgeries.

Following a lumbar puncture, the client reports a headache on a pain scale of 8 out of 10. What priority action should the nurse perform? You answered this question Correctly 1. Instruct the client to drink at least 8 ounces of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints.

3. Correct: The most frequent cause of headache following a lumbar puncture is loss of, or leaking, of cerebrospinal fluid from the puncture site. Positioning a client is an important nursing responsibility, particularly in this situation since the supine position could help to stop any leaking. Following this, the nurse will pursue additional actions as ordered by the primary healthcare provider, which may include increasing fluids or even a blood patch. 1. Incorrect: Although increasing fluids may help clients under specific circumstances, it is not the priority action in this situation. Additionally, the primary healthcare provider may order IV fluids rather than PO fluids. 2. Incorrect: A darkened room can be beneficial for clients with severe migraine headaches, but would not be useful to this client. Headaches following a lumbar puncture are caused by the loss of cerebrospinal fluid and would not respond to a quiet, dark environment. 4. Incorrect: Although the primary healthcare provider should indeed be notified of this situation, the nurse's priority action should first focus on stabilizing the client by addressing the cause of this problem and positioning the client.

An elderly client comes to the clinic for a check-up. The client's daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptom? You answered this question Correctly 1. Confabulation 2. Apraxia 3. Pseudodementia 4. Sundowning

4. Correct: Sundowning is a phenomenon where symptoms seem to worsen in the late afternoon and evening. Communication becomes more difficult, with increasing loss of language skills. Institutional care is usually required at this stage. 1. Incorrect: Confabulation is the term used for creating imaginary events to fill in memory gaps. This is sometimes associated with dementia, but more often with disorders like Korsakoff's syndrome, traumatic brain injuries or tumors. 2. Incorrect: Apraxia is the term used for the inability to carry out motor activities despite intact motor function. 3. Incorrect: Pseudodementia is depression. Depression is the most common mental illness in the elderly, but it is often misdiagnosed and treated inadequately. Cognitive symptoms of depression may mimic dementia.

Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy? You answered this question Incorrectly 1. Drooping of one side of the face. 2. Inability to wrinkle forehead. 3. Excessive tearing. 4. Decreased sensitivity to sound. 5. Inability to taste. 6. Numbness of affected side of face.

Bell's palsy is a paralysis or weakness of the muscles on one side of your face. Damage to the facial nerve that controls muscles on one side of the face causes that side of to droop. The nerve damage may also affect the client's sense of taste and the amount of tears and saliva produced. This condition comes on suddenly, often overnight, and usually gets better on its own within a few weeks. Looking at the options. Which ones are associated with this diagnosis? Did you pick options 1, 2, 3, 5, and 6? Good for you. Why is option 4 wrong? The client will actually have increased sensitivity to sound. Hyperacusis also sometimes appears after 7th nerve (Bells palsy) injuries, which paralyze one of the two small ear muscles that protect the ear from loud noise.

The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? You answered this question Incorrectly 1. Abdominal cramping 2. Lethargy 3. Salivation 4. Hypertension 5. Lacrimation 6. Miosis

Cholinergic crisis is an episode of excessive stimulation to one of the body's neuromuscular junction points. Such an event results from a buildup of acetylcholine stemming from acetylcholinesterase inactivity or insufficiency. A common cause of cholinergic crisis episodes is the unintended overdose of treatment drugs in myasthenia gravis clients. Remember DUMBELLS - Diarrhea and abdominal cramping, Urination increased, Miosis (pinpoint pupils), Bradycardia, Emesis (nausea and vomiting), Lacrimation, Lethargy, Salivation to help you remember these signs and symptoms.

A client with schizophrenic disorder begins to talk about their delusions. What would be the most appropriate nursing action? You answered this question Correctly 1. Encourage the client to focus on reality-based issues. 2. Allow the client to continue to talk about the delusions. 3. Ask the client to explain the meaning behind what is being said. 4. Point out to client that this is not healthy functioning.

Correct: Get them out of the fantasy and into the real world. 2. Incorrect: Do not allow client to continue in a fantasy....this is reinforcing it. 3. Incorrect: This is not appropriate as the client is talking about a delusion. 4. Incorrect: This is not helpful and may cause more anxiety.

When is LP contraindicated?

ICP - will cause brain herniation

The nurse is caring for a client who is receiving enoxaparin after a diagnosis of deep vein thrombosis of the left leg. Which nursing interventions would be appropriate for this client? You answered this question Incorrectly 1. Monitor PT and aPTT 2. Initiate bedrest 3. Apply cool, moist packs to left leg 4. Elevate left leg 5. Monitor closely for bleeding 6. Monitor complete blood count

Look at the hints in this question: "enoxaparin", "DVT", "appropriate interventions". Deep vein thrombosis (DVT) occurs when a thrombus forms in one or more of the deep veins in the body, usually in the legs. A DVT can cause leg pain or swelling, but may occur without any symptoms. Deep vein thrombosis can develop with certain medical conditions that affect how the blood clots. It can also happen if the client does not move for a long time, such as after surgery, following an accident, sitting for long periods of time, such as when driving or flying or when confined to a bed. Deep vein thrombosis is a serious condition because blood clots can break loose, travel through the bloodstream and lodge in the lungs, blocking blood flow (pulmonary embolism). Enoxaparin is a low molecular weight heparin. It works by blocking the formation of blood clots, so bleeding precautions are necessary. Lab tests include complete blood cell counts, platelet counts and tests for blood in the stool. Option 1: False. When administered at recommended prophylaxis doses, routine coagulation tests such as Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are relatively insensitive measures of Enoxaparin Option 2: True. If the client gets up and ambulates with a clot in the leg, that clot can dislodge and traveling to the heart, lung, or brain, causing pulmonary embolus. Option 3: False. Never apply cold to a vein. Warm, moist heat will decrease inflammation and reduce pain. Option 4: True. Elevating the effected extremity will decrease swelling and promote venous return. Option 5: True. The client taking enoxaparin will be a risk of bleeding. Bleeding assessment and bleeding precautions are essential. Option 6: True. A CBC will let the nurse know if the client is bleeding.

receptive vs expressive aphasia

Receptive Aphasia: unable to comprehend speech (Wernicke's area) Expressive Aphasia: comprehends speech but can't respond back with the correct words, if at all (Broca's area) Global Aphasia: complete inability to understand speech or produce it.

GUILLIAN-BARRE' SYNDROME : disease discription

autoimmune, happens about 2 weeks after URI or gasto infection paralysis starts from feet up - peaks in 2 weeks will recover, takes 1-2 years to go back to normal PT/OT **watch respiratory status, will probably need trach

what reflex is not normal in adult but normal in child up to 1 year

babinski toes should curl when foot is stroked

difference in CSF for viral and bacterial meningitis

bacterial - cloudy, high protein, low glucose viral - cloudy, high protein, normal glucose

isolation precautions for bacterial and viral meningitis

bacterial - droplet (high mortality, immunizations recommended) viral - contact (spread through feces, seen in children)

tx for seizure

during seizure - lorazepam and diazepam long acting - phenytoin

sx of ICP

early: LOC slurred speech headache restless projectile vomiting late: change in vital signs (systolic htn, widened pulse pressure, slow HR, irregular respirations) posturing

what is a lumbar puncture used

get spinal fluid to analyze for infection administer drugs into brain or spinal cord (intrathecally)

2 types of strokes how to tell

ischemic (thrombolitic and embolic) hemorrhagic CT scan

2 clinical signs of meningitis

kernigs - knee to chest brudzinskis - head to chest

left vs right sided stroke

left - Right side Hemiplegia Aphasia (trouble formulating words and comprehending them) Aware of their limits...experiences depression, anger, frustration Trouble understanding written text Can't write (agraphia) Impaired math skills right - Left side weakness: Hemiplegia Impairment in creativity: arts and music Confused on date, time, place Cannot recognize faces or the person's name Loss of depth perception Trouble staying on topic when talking Emotionally: not going to think things through....very impulsive

MS patho and sx

progressive demyelination of CNS Symptoms vary among patients because different areas of the central nervous system are affected (symptoms can appear and then disappear)

what does an EEG do

records electrical activity in the brain helps diagnose seizure disorders evaluates LOC and dementia indicator for brain death

tx of meningitis

seizure precautions monitor for increased ICP - HOB 30-45 steroids pain meds antibiotics if bacterial

what happens in autonomic dysreflexia, what is the tx

severe htn, sweating, blur vision usually caused by full bladder or fecal impaction (stimulus that occurs below the spinal cord lesion) tx: sit pt up find cause, remove it teach prevention measures

what spinal cord region causes paraplegic

t1 and below