neuro

cerebral aneurysm

A saclike dilation of the wall of a cerebral artery, typically resulting from weakness of the wall. A cerebral, or berry, aneurysm usually occurs in the circle of Willis and is prone to rupture.A saclike dilation of the wall of a cerebral artery, typically resulting from weakness of the wall. A cerebral, or berry, aneurysm usually occurs in the circle of Willis and is prone to rupture.

telegraphic

ADJECTIVE of or by telegraphs or telegrams: "the telegraphic transfer of the funds" (especially of speech) omitting inessential words; concise

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: 1. provide instructions on eye patching. 2. assess the client's visual acuity. 3. demonstrate eyedrop instillation. 4. teach about intraocular lens cleaning.

Correct Answer: 3 Your Answer: 1 RATIONALES: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

A client is thrown from an automobile during a collision. The nurse knows that the client will be able to maintain gross arm movements and diaphragmatic breathing if the injury occurs at what vertebral level? 1. C4 2. C5 3. C3 4. C7

RATIONALES: A client with a spinal cord injury at or above the level of the fourth cervical vertebra (C4) can't breathe spontaneously. With an injury below this level, diaphragmatic breathing occurs. An injury from C5 to C6 results in quadriplegia, with diaphragmatic breathing and gross arm movements. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

Neurosensory Disorders Review Question 76 of 156 A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear? 1. External ear 2. Middle ear 3. Inner ear 4. Tympanic membrane

RATIONALES: A client with vertigo experiences problems with the inner ear. The inner ear 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. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension

A client with tonic-clonic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Which instructions about phenytoin should the nurse give this client? Select all that apply: 1. Monitor for skin rash. 2. Maintain adequate amounts of fluid and fiber in the diet. 3. Perform good oral hygiene, including daily brushing and flossing. 4. Periodic follow-up blood work is necessary. 5. Report to the physician problems with walking and coordination, slurred speech, or nausea. 6. Phenytoin may be taken during pregnancy.

RATIONALES: A rash may occur 10 to 14 days after starting phenytoin. If a rash appears, the client should notify the physician and discontinue the medication. Because phenytoin may cause gingival hyperplasia, the client must practice good oral hygiene and see a dentist regularly. Periodic blood work is necessary to monitor complete blood counts, platelet levels, hepatic function, and drug levels. Signs and symptoms of phenytoin toxicity include problems with walking and coordination, slurred speech, nausea, lethargy, diplopia, nystagmus, and disturbances in balance. These symptoms must be reported to the physician immediately. Although adequate amounts of fluid and fiber are part of a healthy diet, they aren't required for a client taking phenytoin. Phenytoin must be used cautiously during pregnancy because of the increased incidence of birth defects; phenobarbital is a safer drug to take during pregnancy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

A client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? 1. Phenytoin (Dilantin) 2. Mannitol (Osmitrol) 3. Lidocaine (Xylocaine) 4. Furosemide (Lasix)

RATIONALES: Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, they're administered parenterally, not endotracheally. Phenytoin doesn't reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isn't administered endotracheally. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Knowledge

When communicating with a client who has sensory (receptive) aphasia, the nurse should: 1. allow time for the client to respond. 2. speak loudly and articulate clearly. 3. give the client a writing pad. 4. use short, simple sentences.

RATIONALES: Although receptive aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful, but it's less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

A client has an exacerbation of multiple sclerosis accompanied by leg spasticity. The physician prescribes dantrolene sodium (Dantrium), 25 mg by mouth daily. How soon after administration can the nurse expect to see a significant reduction in spasticity? 1. 30 to 45 minutes 2. 6 to 12 hours 3. 2 to 3 days 4. 1 to 2 weeks

RATIONALES: Although the peak concentration level of a single dose of dantrolene occurs about 5 hours after it's ingested, the drug's therapeutic benefit may not be evident for a week or more. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Knowledge

The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is: 1. delirium. 2. depression. 3. excessive drug use. 4. Alzheimer's disease.

RATIONALES: Alzheimer's disease is the most common cause of dementia in the elderly. About 5% of people older than age 65 have severe cases of Alzheimer's disease, and about 12% of people older than age 65 have mild or moderate cases of the disease. Delirium, or acute confusion, is caused by an underlying disease and isn't itself a cause of dementia. Depression is common in the elderly but tends to manifest itself in apathy, self-deprecation, or inertia — not dementia. Excessive drug use, commonly stemming from the elderly client seeing multiple physicians who are unaware of drugs that other physicians have prescribed, can cause dementia, but this problem isn't as common as Alzheimer's disease. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and heaviness. During the admission process, the client presents her advance directive, which states that she doesn't want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse respond? 1. "Thank you for providing this document; I'll include it in your permanent record." 2. "Advance directives aren't necessary for clients your age." 3. "It's important for us to have this information. You should review the document with your physician at every admission." 4."Your disease hasn't progressed enough to institute an advance directive."

RATIONALES: 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 portions of the advance directive may be inappropriate if a particular condition is reversible and temporary. Option 1 doesn't address the need to review the directive with the physician. Advance directives are appropriate for clients of all ages. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Coordinated care COGNITIVE LEVEL: Application

In a client with amyotrophic lateral sclerosis and respiratory distress, which finding is the earliest sign of reduced oxygenation? 1. Decreased heart rate 2. Increased restlessness 3. Increased blood pressure 4. Decreased level of consciousness (LOC)

RATIONALES: An early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

A physician diagnoses a client with myasthenia gravis and prescribes pyridostigmine (Mestinon), 60 mg by mouth every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine? 1. Ulcerative colitis 2. Blood dyscrasia 3. Intestinal obstruction 4. Spinal cord injury

RATIONALES: Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and spinal cord injury don't contraindicate use of the drug. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Analysis

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: 1. increase the frequency of the catheterizations. 2. insert an indwelling urinary catheter. 3. place the client on fluid restrictions. 4. use a condom catheter instead of an invasive one.

RATIONALES: 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 (UTI) 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 a client with urine retention. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? 1. Parasympathomimetic agent 2. Sympatholytic agent 3. Adrenergic blocker 4. Cholinergic blocker

RATIONALES: Atropine sulfate is a cholinergic blocker. It isn't a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Knowledge

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? 1. Administering chloral hydrate (Noctec) 2. Assessing laboratory test results as ordered 3. Placing the client in Trendelenburg's position 4. Monitoring the patency of an indwelling urinary catheter

RATIONALES: Because a full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering chloral hydrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? 1. Administering chloral hydrate (Noctec) 2. Assessing laboratory test results as ordered 3. Placing the client in Trendelenburg's position 4. Monitoring the patency of an indwelling urinary catheter

RATIONALES: Because a full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering chloral hydrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement? 1. Give the medication on an empty stomach. 2. Warn the client that he'll experience mouth dryness. 3. Schedule the medication before meals. 4. Administer the medication for complaints of muscle weakness or difficulty wallowing.

RATIONALES: Because neostigmine's onset of action is 45 to 75 minutes, it should be administered at least 45 minutes before eating to improve chewing and swallowing. Taking neostigmine with a small amount of food reduces GI adverse effects. Adverse effects of the medication include increased salivation, bradycardia, sweating, nausea, and abdominal cramps. Neostigmine must be given at scheduled times to ensure consistent blood levels. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? 1. Ambenonium (Mytelase) 2. Pyridostigmine (Mestinon) 3. Edrophonium (Tensilon) 4. Carbachol (Carboptic)

RATIONALES: Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? 1. Disturbed sensory perception (visual) 2. Dressing or grooming self- care deficit 3. Impaired verbal communication 4. Risk for injury

RATIONALES: Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although the other options may be appropriate, they're secondary because they don't immediately affect the client's health or safety. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application

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 does Brudzinski's sign indicate? 1. Increased intracranial pressure (ICP) 2. Cerebral edema 3. Low cerebrospinal fluid (CSF) pressure 4. Meningeal irritation

RATIONALES: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low CSF pressure. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension

A client is color blind. The nurse understands that this client has a problem with: 1. rods. 2. cones. 3. lens. 4. aqueous humo

RATIONALES: Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid that isn't involved with color perception. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture? Select all that apply: 1. Flexion of the arms and wrists with internal rotation 2. Wrist pronation 3. Stiff extension of the arms and legs 4. Plantar flexion of the feet 5. Opisthotonos

RATIONALES: Decerebrate posture, which results form damage to the upper brain stem, is characterized by adduction and stiff extension of the arms. These findings are accompanied by wrist pronation, finger flexion, opisthotonos, and stiff extension of the legs with plantar flexion of the feet. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? 1. Diencephalon 2. Medulla 3. Midbrain 4. Cortex

RATIONALES: Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? 1. Imbalanced nutrition: Less than body requirements 2. Ineffective airway clearance 3. Impaired urinary elimination 4. Risk for injury

RATIONALES: In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate for this client, they aren't immediately life-threatening. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

When caring for a client with a head injury, the nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? 1. Rising blood pressure and bradycardia 2. Hypotension and bradycardia 3. Hypotension and tachycardia 4. Hypertension and narrowing pulse pressure

RATIONALES: Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledg

A client injured in a train derailment is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: 1. hypoxia. 2. fever. 3. visual disturbance. 4. gait alteration.

RATIONALES: Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

The nurse is planning care for a client with multiple sclerosis. Which problems should the nurse expect the client to experience? Select all that apply: 1. Visual disturbances 2. Coagulation abnormalities 3. Balance problems 4. Immunity compromise 5. Mood disorders

RATIONALES: Multiple sclerosis, a neuromuscular disorder, may cause visual disturbances, balance problems, and mood disorders. Multiple sclerosis doesn't cause coagulation abnormalities or immunity problems. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A client recovering from a stroke has right-sided hemiplegia and telegraphic speech and often seems frustrated and agitated, especially when trying to communicate. However, the chart indicates that the client's auditory and reading comprehension are intact. The nurse suspects that the client has: 1. global aphasia. 2. nonfluent aphasia. 3. fluent aphasia. 4. anomic aphasia.

RATIONALES: Nonfluent aphasia is characterized by telegraphic speech, failure to use conjunctions and pronouns, and impaired repetition and ability to read aloud. In global aphasia, spontaneous speech is absent or limited to a few stereotyped words; comprehension is limited to the client's name or a few words. In fluent aphasia, auditory comprehension is disturbed; speech lacks meaningful content, is unrelated to questions, and includes paraphasias. The client with fluent aphasia seems unaware that speech doesn't make sense and that reading and writing are impaired. In anomic aphasia, the client can't name objects, has trouble finding words, and may be unable to read or write. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure. She monitors his blood pressure for signs of widening pulse pressure. His current blood pressure is 170/80 mm Hg. What is the client's pulse pressure?

RATIONALES: Pulse pressure is the difference between the systolic blood pressure and the diastolic blood pressure. For this client, pulse pressure is 170 − 80 = 90. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

Neurosensory Disorders Review Question 75 of 156 A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints? 1. Make sure that the restraints fit snuggly to restrict the client from reaching his nose, arms, or perineal area. 2. Apply one wrist restraint at a time. 3. Fasten the restraint to the bed frame using a quick- release knot. 4. Place a sign over the client's bed warning staff to avoid removing the restraints.

RATIONALES: Restraints should be used only when less restrictive measures have failed to ensure the safety of the client or others. When restraints are necessary, they should be fastened to the bed frame using a quick-release knot and applied loosely, not snuggly, to prevent injury. The client should be assessed frequently and the restraints should be removed whenever possible to encourage movement. Applying only one restraint at a time wouldn't prevent the client from removing necessary medical equipment, such as a feeding tube, I.V. catheter, or indwelling urinary catheter. It's inappropriate to place a sign over the client's bed instructing staff to avoid removing the restraints. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application

The nurse is assessing a 2-year-old client diagnosed with bacterial meningitis. Which of the following signs and symptoms of meningeal irritation is the nurse likely to observe? 1. Generalized seizures 2. Nuchal rigidity 3. Positive Brudzinski's sign 4. Positive Kernig's sign 5. Babinski reflex 6. Photophobia

RATIONALES: Signs of meningeal irritation include nuchal rigidity, positive Brudzinski's and Kernig's signs, and photophobia. Other signs of meningeal irritation are exaggerated and symmetrical deep tendon reflexes, as well as opisthotonos (a spasm in which the back and extremities arch backward so that the body rests on the head and heels). Generalized seizures, which may accompany meningitis, are caused by irritation to the cerebral cortex, not meningeal irritation. Babinski reflex is a reflex action of the toes that reflects corticospinal tract disease in adults. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease? 1. I 2. II 3. III 4. IV

RATIONALES: Stage II is exhibited by the above listed symptoms as well as communication difficulties, motor disturbances, forgetfulness, and psychosis. This stage lasts 2 to 10 years. Stage I, which lasts 1 to 3 years, is characterized by memory loss, poor judgment and problem-solving, difficulty adapting to new environments and challenges, and agitation or apathy. Stage III is characterized by loss of all mental abilities and the ability to care for self. There is no stage IV. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

After an eye examination, a client is diagnosed with open-angle glaucoma. The physician's prescription says "pilocarpine ophthalmic solution (Pilocar), 0.25% 1 gtt both eyes q.i.d." Based on this prescription, the nurse should teach the client or a family member to administer the drug by: 1. instilling one drop of pilocarpine 0.25% into both eyes daily. 2. instilling one drop of pilocarpine 0.25% into both eyes four times daily. 3. instilling one drop of pilocarpine 0.25% over the lacrimal duct of both eyes four times daily. 4. instilling one drop of pilocarpine 0.25% towards the nasal side of each conjunctival sac three times daily.

RATIONALES: The abbreviation "q.i.d." means four times per day. The abbreviation "gtt" stands for drop. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

While bathing a client who sustained a stroke, a nurse is asked by a coworker to assist with repositioning another client. What should the nurse do? 1. Ensure the client's privacy, put up the side rail, and that she'll return shortly. 2. Explain that she must leave and ask the client to continue bathing. 3. Leave the client and return as soon as possible. 4. Explain to her coworker that she can't leave the client until she's finished bathing him.

RATIONALES: The best approach is to explain to the client that she needs to leave, put up the side rail, and ensure the client's privacy. The client can't continue bathing independently; suggesting that he do so might frustrate him. The nurse shouldn't leave the client without an explanation, and she shouldn't refuse to help her coworker. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application

A client is admitted to the medical-surgical unit after undergoing intracranial surgery to remove a tumor from the left cerebral hemisphere. Which nursing interventions are appropriate for the client's postoperative care? Select all that apply: 1. Place a pillow under the client's head so that his neck is flexed. 2. Turn the client on his right side. 3. Place pillows under the client's legs to promote hip flexion and venous return. 4. Maintain the client in the supine position. 5. Apply a soft collar to keep the client's neck in a neutral position.

RATIONALES: The client should be turned on his right side because lying on the left side would cause the brain to shift into the space previously occupied by the tumor. A soft collar keeps the neck in a neutral position, allowing for adequate perfusion and venous drainage of the brain. Placing a pillow under the head flexes the neck and impairs circulation to the brain. Flexion of the hip increases intracranial pressure and, therefore, is contraindicated. Exclusive use of the supine position isn't indicated. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A client is admitted to the medical-surgical unit after undergoing intracranial surgery to remove a tumor from the left cerebral hemisphere. Which nursing interventions are appropriate for the client's postoperative care? Select all that apply: 1. Place a pillow under the client's head so that his neck is flexed. 2. Turn the client on his right side. 3. Place pillows under the client's legs to promote hip flexion and venous return. 4. Maintain the client in the supine position. 5. Apply a soft collar to keep the client's neck in a neutral position.

RATIONALES: The client should be turned on his right side because lying on the left side would cause the brain to shift into the space previously occupied by the tumor. A soft collar keeps the neck in a neutral position, allowing for adequate perfusion and venous drainage of the brain. Placing a pillow under the head flexes the neck and impairs circulation to the brain. Flexion of the hip increases intracranial pressure and, therefore, is contraindicated. Exclusive use of the supine position isn't indicated. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? 1. Give him a barbiturate. 2. Place him on mechanical ventilation. 3. Perform a lumbar puncture. 4. Elevate the head of his bed.

RATIONALES: The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? 1. Give him a barbiturate. 2. Place him on mechanical ventilation. 3. Perform a lumbar puncture. 4. Elevate the head of his bed.

RATIONALES: The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. What should the nurse tell the client about the paralysis? 1. "The paralysis caused by this disease is temporary." 2. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." 3. "It must be hard to accept the permanency of your paralysis." 4. You'll first regain use of your legs and then your arms."

RATIONALES: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension

A client who experienced a severe stroke develops a fever and a cough that produces thick, yellow sputum. A nurse observes sediment in the client's urine in the indwelling urinary catheter tubing. Based on these findings, which action should the nurse take? 1. Change the client's indwelling urinary catheter. 2. Notify a physician of the findings. 3. Encourage coughing and deep-breathing exercises. 4. Contact central supply to request a respiratory isolation cart.

RATIONALES: The nurse should notify the physician of these findings because they're signs of pneumonia and a urinary tract infection. The physician will most likely order sputum and urine specimens for culture and sensitivity testing. After the specimens are obtained, the physician will most likely prescribe antibiotic therapy. Coughing and deep-breathing exercises can also be implemented to mobilize secretions, but a client who sustains a severe stroke may not be able to perform these exercises. Nothing suggests that the client requires respiratory isolation at this time. The physician may provide an order to discontinue or change the indwelling urinary catheter. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis

The nurse is planning care for a client who suffered a stroke in the right hemisphere of his brain. What should the nurse do? 1. Anticipate that the client will exhibit some degree of expressive or receptive aphasia. 2. Place the wheelchair on his left side when transferring the client into a wheelchair. 3. Provide close supervision because of the client's impulsiveness and poor judgment. 4. Support his right arm with a sling or pillow to prevent subluxation.

RATIONALES: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

Damage to which area of the brain results in receptive aphasia? 1. Parietal lobe 2. Occipital lobe 3. Temporal lobe 4. Frontal lobe

RATIONALES: The temporal lobe contains the auditory association area. If the area is damaged in the dominant hemisphere, the client hears words but doesn't know their meaning. Damage to the parietal lobe affects the client's ability to identify special relationships with the environment. When damaged, the occipital lobe affects visual associations. The client can visualize objects but can't identify them. The frontal lobe acts as a storage area for memory. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension

The nurse is preparing to administer carbamazepine (Tegretol) oral suspension, 150 mg by mouth. The pharmacy has dispensed carbamazepine suspension 100 mg/5 ml. How many milliliters of carbamazepine should the nurse administer

RATIONALES: To calculate the dose, the nurse should use this equation: 100 mg/5 ml = 150 mg/X 100X = 750 X = 7.5 ml. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine (Cogentin), 0.5 mg by mouth daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine? 1. "I take the medication when I get up in the morning." 2. "I take the medication with a meal." 3. "I take the medication after a meal." 4. "I take the medication at bedtime."

RATIONALES: To minimize the risk of adverse drug reactions, the client should take benztropine as a single dose at bedtime. Taking it on arising in the morning or taking it with or after a meal wouldn't minimize adverse effects. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Analysis

The nurse is performing a neurologic assessment on a client with a head injury. To assess the Babinski reflex, where would the nurse initially place the tongue blade?

RATIONALES: To test for the Babinski reflex, the nurse should use a tongue blade to slowly stroke the lateral side of the underside of the foot. Start at the heel and move towards the great toe. The normal response in an adult is plantar flexion of the toes. Upward movement of the great toe and fanning of the little toes, called the Babinski reflex, is abnormal. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension

The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal? 1. More back pain than the first postoperative day 2. Paresthesia in the dermatomes near the wound 3. Urine retention or incontinence 4. Temperature of 99.2° F (37.3° C)

RATIONALES: Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery. An increase in pain on the second postoperative day is common because the long-acting local anesthetic, which may have been injected during surgery, will wear off. Whereas 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 it reaches 101° F (38.3° C). NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? 1. The client leaves the side rails down. 2. The client uses a mirror to inspect his skin. 3. The client repositions only after being reminded to do so. 4. The client hangs his left arm over the side of the wheelchair.

RATIONALES: Using a mirror enables the client to inspect all areas of his skin for signs of breakdown without the help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent falls. The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it, if needed. A client with left-side paralysis may not realize that his left arm is hanging over the side of the wheelchair. However, the nurse should call this to the client's attention because his arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position too long. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

What should the nurse do when administering pilocarpine (Pilocar)? 1. Apply pressure on the inner canthus to prevent systemic absorption. 2. Administer at bedtime to prevent night blindness. 3. Apply pressure on the outer canthus to prevent adverse reactions. 4. Flush the client's eye with normal saline solution to prevent burning.

RATIONALES: 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. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

The nurse is teaching a client with a T4 spinal cord injury and paralysis of the lower extremities how to transfer from the bed to a wheelchair. The nurse should instruct the client to move: 1. his upper and lower body into the wheelchair simultaneously. 2. his upper body to the wheelchair first. 3. his feet to the wheelchair pedals and then his hands to the wheelchair arms. 4. his feet to the floor and then his buttocks to the wheelchair seat.

RATIONALES: When transferring from a bed to a wheelchair, a client with paralysis of the lower extremities should move the strong part of his body to the chair first. Therefore, the client should move his upper body to the chair and then move his legs from the bed to the chair. The other techniques aren't safe for the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed? 1. In 30 to 45 seconds 2. In 10 to 15 minutes 3. In 30 to 45 minutes 4. In 1 to 2 hours

RATIONALES: When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn't exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose can't be repeated in 30 to 45 seconds because the first dose wouldn't have been administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the client's risk of complications associated with status epilepticus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Knowledge

autonomic dysreflexia

Reaction that may occur in clients with spinal cord injury above T6. Dysreflexia results in profuse diaphoresis, pounding headache, blurred vision, and dramatically elevated blood pressure. This life-threatening reaction may occur even from seemingly minor stimuli, such as lying on a wrinkled sheet or having a full bladder.