neuro NCLEX
A nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding would be an early indication that the level of consciousness (LOC) is deteriorating?
*1. Drowsiness* 2. Clear speech 3. Ptosis of the left eyelid 4. Frequent spontaneous speech *rationale* Early changes in LOC relate to orientation, alertness, and verbal responsiveness. Less frequent speech, slight slurring of speech, and mild drowsiness are early signs of decreasing LOC. Ptosis of the eyelid is due to pressure on and dysfunction of cranial nerve III and does not relate to LOC.
The nurse caring for an older adult client understands that which of the following can increase disorientation in this client? *Select all that apply.*
*1. Sedatives* *2. Anesthesia* *3. Analgesics* 4. Ambulation 5. Frequent visitors *6. Physical restraints* *rationale* Using sedatives, anesthesia, analgesics, physical restraints, and tranquilizers can increase disorientation in the older adult client. Ambulation and frequent visitors can assist in orientation of the client due to the stimulation these activities provide..
A nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? *Select all that apply.*
*1. Suction machine* *2. Oxygen administration* *3. Padding for the side rails* 4. Padded tongue blade *5. Prescribed diazepam (Valium)* *rationale* Full seizure precautions include bedrest with padded side rails in a raised position, a suction machine at the bedside, having diazepam (Valium) or lorazepam (Ativan) available, and oxygen. Objects such as tongue blades are not necessary and should never be placed in the client's mouth during a seizure.
A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which of the following items?
*1. Walker* 2. Slider board 3. Raised toilet seat 4. Adaptive eating utensils *rationale* The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. Adaptive eating utensils may be beneficial when the client has partial paralysis of the hand. A raised toilet seat is useful when the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a client from a bed to stretcher or wheelchair.
A nurse is planning care for the client with hemiparesis of the right arm and leg. The nurse incorporates in the care plan placement of objects:
*1. Within the client's reach, on the left side* 2. Within the client's reach, on the right side 3. Just out of the client's reach, on the left side 4. Just out of the client's reach, on the right side *rationale* Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. Other helpful activities with hemiparesis include range-of-motion exercises to the affected side and muscle-strengthening exercises to the unaffected side.
A nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs additional information if the client made which of the following statements?
1. "I will wash my face with cotton pads." 2. "I'll have to start chewing on the unaffected side." 3. "I should rinse my mouth if toothbrushing is painful." *4. "I will try to eat my food either very warm or very cold."* *rationale* Facial pain can be minimized by using cotton pads to wash the face, using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If toothbrushing triggers pain, sometimes an oral rinse after meals is more helpful.
A nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client states:
1. "Alcohol is not contraindicated while taking this medication." *2. "Good oral hygiene is needed, including brushing and flossing."* 3. "The medication dose may be self-adjusted, depending on side effects." 4. "The morning dose of the medication should be taken before a sample for a serum drug level is drawn." *rationale* Typical anticonvulsant medication instructions include taking the prescribed dose daily to keep the blood level of the drug constant; having a serum drug level drawn before taking the morning dose; avoiding abruptly stopping the medication; avoiding alcohol; checking with the health care provider before taking over-the-counter medications; avoiding activities in which alertness and coordination are required until medication effects are known; providing good oral hygiene and getting regular dental care; and wearing a Medic-Alert bracelet or tag.
A nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria if the client:
1. Wears a turban to cover the incision *2. Indicates that facial puffiness will be a permanent problem* 3. Verbalizes that periorbital bruising will disappear over time 4. States an intention to purchase a hairpiece until the hair has grown back *rationale* After craniotomy, the client may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (which are temporary). The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.
An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which of the following is consistent with normal findings?
1. White blood cells *2. Red blood cells* 3. Protein 4. Glucose *rationale* The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0 to 3 per mm3). Protein (15 to 45 mg/dL) and glucose (40 to 80 mg/dL) are normally present in CSF.
A nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further instruction?
*1. "I will not hear sounds clearly unless they are loud."* 2. "If I tend to have seizures or gets dizzy spells, someone should be with me while walking." 3. "I need to use a check-off system for my anticonvulsant medications to avoid missing doses." 4. "A tub bath or shower is permitted, but I need to keep my scalp dry until the sutures are removed." *rationale* Seizures are a complication that can occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of doses administered. The family should learn seizure precautions and accompany the client while ambulating if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection. The postcraniotomy client can hear sounds, is typically sensitive to loud noises, and can find them irritating (e.g., loud television). Awareness control of environmental noise by others is helpful to this client.
A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which of the following would be an appropriate response by the nurse?
*1. "I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father."* 2. "I need to place you in restraints." 3. "How old are you? Your father must no longer be living." 4. "I need you to sign a form before leaving." *rationale* The correct response acknowledges the client's comment and feelings. Option 3 does not preserve the client's dignity. Option 2 is inappropriate and is inconsistent with legal aspects of care based on the information given. Option 4 fails to protect the client from possible harm.
A nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history will have the least amount of added risk for neurological problems?
*1. Allergy to pollen* 2. History of headaches 3. Previous back injury 4. History of hypertension *rationale* Previous neurological problems such as headaches or back injuries place the client more at risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment of allergies is a routine part of the health history, regardless of the nature of the client's problem. In addition, an allergy to pollen would not place the client at risk for a neurological problem.
A nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which of the following findings would be associated with spinal shock in this client? *Select all that apply.*
*1. Bowel sounds are absent.* *2. The client's abdomen is distended.* *3. Respiratory excursion is diminished.* 4. The blood pressure rises when the client sits up. *5. Accessory muscles of respiration are areflexic.* *rationale* During the period of areflexia that characterizes spinal shock, the blood pressure may fall when the client sits up. The bowel and bladder often become flaccid, may become distended, and fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation.
A nurse reviews the health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription, if noted in the client's record, should the nurse question?
*1. Clear liquid diet* 2. Vital signs every 2 to 4 hours 3. Bilateral calf measurements three times daily 4. Passive range-of-motion exercises three times daily *rationale* Clients with Guillain-Barré syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods. Clients with Guillain-Barré syndrome are at risk for hypotension or hypertension, bradycardia, and respiratory depression and require frequent monitoring of vital signs. Passive range-of-motion exercises can help prevent contractures, and checking calf measurements can help detect deep vein thrombosis, for which clients are at risk.
A nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which of the following indicates an early sign of increased ICP?
*1. Confusion* 2. Bradycardia 3. Sluggish pupils 4. A widened pulse pressure *rationale* Early manifestations of increased ICP are subtle and may often be transient, lasting for only a few minutes in some cases. These early clinical manifestations include changes in level of consciousness, including episodes of confusion and drowsiness, and slight pupillary and breathing changes. Clinical manifestations of later increased ICP include decreasing levels of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and sluggish and dilating pupils appear in the later stages.
A nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client should be asked to:
1. Extend the arms. *2. Extend the tongue.* 3. Turn the head toward the nurse's arm. 4. Focus the eyes on the object held by the nurse. *rationale* To assess the function of cranial (hypoglossal) nerve XII, the nurse would assess the client's ability to extend the tongue. Options 1, 3, and 4 are unrelated to assessing this cranial nerve.
A nurse is monitoring a client with a head injury and notes that the client is assuming this posture. The nurse notifies the registered nurse immediately to report that the client is exhibiting: Refer to figure.
*1. Decorticate posturing* 2. Decerebrate posturing 3. Flaccid quadriplegia 4. Opisthotonos *rationale* In decorticate posturing, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate posturing indicates a hemispheric lesion of the cerebral cortex. In decerebrate posturing, the upper extremities are extended stiffly and adducted with internal rotation and pronation of the palms. The lower extremities are extended stiffly with plantar flexion. The teeth are clenched and the back is hyperextended. Decerebrate posturing indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brainstem. Opisthotonos is prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation.
A client has just undergone computed tomography (CT) scanning with a contrast medium. The nurse determines that the client understands postprocedure care if the client verbalizes that he or she will:
*1. Drink extra fluids for the day.* 2. Hold medications for at least 4 hours. 3. Eat lightly for the remainder of the day. 4. Rest quietly for the remainder of the day. *rationale* After CT scanning, the client may resume all usual activities. The client should be encouraged to take in extra fluids to replace those lost with diuresis from the contrast dye. Options 2, 3, and 4 are unnecessary.
A nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle accident. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation?
*1. Extension of the extremities and pronation of the arms* 2. Flexion of the extremities and pronation of the arms 3. Upper extremity flexion with lower extremity extension 4. Upper extremity extension with lower extremity flexion *rationale* Decerebrate posturing (abnormal extension), which is associated with dysfunction in the brainstem area, consists of extension of the extremities and pronation of the arms. Posturing is a late sign of deterioration in the client's neurological status and warrants immediate health care provider notification.
A nurse is assigned to care for an adult client who had a brain attack (stroke) and is aphasic. Choose the appropriate interventions for communicating with the client. *Select all that apply.*
*1. Face the client when talking.* *2. Speak slowly and maintain eye contact.* *3. Use gestures when talking to enhance words.* 4. Avoid the use of body language when talking to the client. *5. Give the client directions using short phrases and simple terms.* 6. Phrase what was said differently the second time, if there is a need to repeat it. *rationale* A client who is aphasic has difficulty expressing or understanding language. The nurse would face the client when talking, establish and maintain eye contact, and speak slowly and distinctly. The nurse should use gestures and pantomime when talking to enhance words and use body language to enhance the message. The nurse would give the client directions using short phrases and simple terms, and phrase questions so that they can be answered with a yes or no. If there is a need to repeat something, the nurse should use the same words a second time.
A client with a brain attack (stroke) has residual dysphagia. When a diet prescription is initiated, the nurse avoids doing which of the following?
*1. Giving the client thin liquids* 2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing *rationale* Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.
A nurse is caring for a client with increased intracranial pressure (ICP). The nurse should monitor for which of the following trends in vital signs that would occur if ICP is rising?
*1. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure (BP)* 2. Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP 3. Decreasing temperature, increasing pulse, decreasing respirations, increasing BP 4. Increasing temperature, increasing pulse, increasing respirations, decreasing BP *rationale* A change in vital signs may be a late sign of increased ICP. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities may also arise.
The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. The nurse intervenes, based on the understanding that:
*1. It is possible the client can hear the family.* 2. The family needs immediate crisis intervention. 3. The family could benefit from a conference with the health care provider. 4. The client may have wanted a visit from the hospital chaplain. *rationale* Some clients who have awakened from an unconscious state report that they remember hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is still intact and act accordingly. Research has also demonstrated that positive outcomes are associated with coma stimulation, that is, speaking to and touching the client.
A nurse is assisting to care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?
*1. Leakage of clear fluid from the nose.* 2. Inability to breathe through one nare. 3. Hematoma formation around the eyes. 4. Edema noted around the nose and eyes. *rationale* When a nasal fracture is suspected or diagnosed, the nurse should monitor the client for leakage of clear fluid from the nose as the priority. This could be cerebrospinal fluid (CSF), and may be indicative of cerebral injury. Any discharge of fluid from the nose should be tested to determine whether it is CSF. Inability to breathe through one nare is important to address, but is not the priority in this question since the client is still able to breathe through the other nare and through the mouth. Hematoma formation around the eyes and edema around the nose and eyes are common manifestations of nasal fracture.
A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client? *Select all that apply.*
*1. Listening attentively* 2. Encouraging the client to speak quickly *3. Asking yes and no questions when able* *4. Using a communication board when necessary* *5. Repeating what the client said to verify the* message *rationale* The client has speech that is nasal in tone and dysarthric because of cranial nerve involvement of the muscles governing speech. The nurse listens attentively and verbally, verifies what the client has said, asks questions requiring a yes or no response, and develops alternative communication methods (e.g., letter board, picture board, pen and paper, flash cards). Encouraging the client to speak quickly is an ineffective communication strategy and is counterproductive.
A nurse is reinforcing instructions to a client taking divalproex sodium (Depakote). The nurse tells the client to return to the clinic for follow-up laboratory studies related to which test?
*1. Liver function studies* 2. Renal function studies 3. Glucose tolerance test 4. Electrolyte studies *rationale* Divalproex sodium, an anticonvulsant, can cause hepatotoxicity, which is potentially fatal. The nurse instructs the client to return to the clinic for follow-up liver function studies, such as lactate dehydrogenase (LDH), serum glutamic-oxaloacetic transaminase (SGOT), serum glutamate pyruvate transaminase (SGPT), and ammonia levels. This is especially indicated in the first 6 months of therapy. The laboratory studies identified in the other options are not specifically related to the administration of this medication.
A nurse is turning a postoperative client who had extensive back surgery yesterday. What turning intervention or position would be best for repositioning this client?
*1. Logrolling* 2. Semi-Fowler's 3. Sims' (semi-prone) 4. 30-degree lateral (side-lying) *rationale* Logrolling is used to maintain neck and spinal alignment after injury or surgery. A minimum of three to four staff members is recommended to prevent injury to the client, and a draw or pull sheet is also suggested. Options 2, 3, and 4 do not maintain proper spinal alignment and could be harmful.
A nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which of the following?
*1. Mask-like facies is a component of Parkinson's disease.* 2. Clients with Parkinson's disease have diminished emotional involvement. 3. Clients with Parkinson's disease act very much like schizophrenics, in that they have very little affect. 4. The client does not want her emotional reaction to the disease to show. *rationale* A masked facial expression is typical of the client with Parkinson's disease. Option 2 is not a true statement. Option 3 places a false interpretation on the client's expression. There are no data to support the assumption provided in option 4.
A nurse is planning care for a client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury?
*1. Moving the client quickly as one unit* 2. Applying TEDS or compression stockings 3. Using vasopressor medications, as prescribed 4. Monitoring vital signs before and during position changes *rationale* Reflex vasodilation below the level of spinal cord injury places the client at risk of orthostatic hypotension, which may be profound. Actions to minimize this include measuring vital signs before and during position changes, use of a tilt table in early mobilization, and changing the client's position slowly. Venous pooling can be reduced by using TEDS or compression stockings. Vasopressor medications are used as per protocol and as prescribed.
An older client is at risk for falls. When developing an individualized plan of care for this client, the nurse recalls that which concept is least relevant to maintenance of balance for the older client?
*1. Older clients cannot think quickly enough to respond to emergencies.* 2. Many medications may have orthostatic hypotension as a side effect. 3. Older clients tend to maintain a broad base of support and thus change direction more slowly. 4. Older clients often have slower neurological responses to stimuli. *rationale* It is not true that older clients cannot think quickly enough to respond to emergencies. That statement is a stereotypical generalization. The statements contained in the other options are true.
A client is scheduled for a digital subtraction angiography. The nurse supports the client's understanding that the test is directed toward which outcome?
*1. Providing information about the blood vessels* 2. Examining the cerebral spinal column 3. Injecting medication into the bone 4. Detecting lesions in the brain *rationale* Digital subtraction angiography is a radiographic method to study the blood vessels. The nurse should explain to the client that the test gives instant information about the blood vessels. The remaining options are incorrect.
A client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, the nurse immediately:
*1. Raises the head of the bed and removes the noxious stimulus* 2. Lowers the head of the bed and removes the noxious stimulus 3. Lowers the head of the bed and administers an antihypertensive agent 4. Removes the noxious stimulus and administers an antihypertensive agent *rationale* Key nursing actions are to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. The nurse can also clearly label the client's chart identifying the risk for autonomic dysreflexia. Client and family should be taught to recognize, and later manage, the signs and symptoms of this syndrome.
A nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data would focus on which of the following characteristic of this disease?
*1. Recent memory loss* 2. Difficulty in performing new tasks 3. Problems with concrete thinking 4. Problems with hearing and discriminating the spoken word from other sounds *rationale* Dementia is the hallmark of Alzheimer's disease. Recent memory loss is one characteristic. Others include problems with abstract thinking, problems with speech (not hearing), and difficulty in performing familiar tasks.
Which of the following information will the nurse reinforce to the client scheduled for a lumbar puncture?
1. Food and fluids will be restricted until after the test is completed. 2. There is no need to maintain bedrest following the test. 3. The test will probably take about 2 hours. *4. An informed consent will be required.* *rationale* Client preparation for lumbar puncture includes obtaining informed consent from the client. No dietary or food restrictions are required before the test. The client is told that the test will take approximately 15 to 60 minutes. The nurse needs to inform the client about the need for bedrest following the test.
A nurse is providing care to a client with increased intracranial pressure (ICP). Which approach(es) may be beneficial in controlling the client's ICP from an environmental viewpoint? *Select all that apply.*
*1. Reducing environmental noise* *2. Maintaining a calm atmosphere* *3. Allowing the client uninterrupted time for sleep* 4. Clustering nursing activities to be done all at once 5. Keeping overhead lights on most of the day and night *rationale* Nursing interventions should be spaced out over the shift to minimize the risk of a rise in ICP. If possible, activities known to raise ICP should be avoided when possible. Other interventions to control the ICP include keeping the lighting in the room dim or off, maintaining a calm, quiet environment and avoiding emotional stress and interruption of sleep.
A nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated?
*1. Restrain the client's limbs.* 2. Loosen restrictive clothing. 3. Remove the pillow and raise the padded side rails. 4. Position the client to the side, if possible, with head flexed forward. *rationale* Nursing actions during a seizure include providing privacy, loosening restrictive clothing, removing the pillow and raising the padded side rails in bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained, because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head against injury, and moves furniture that may injure the client.
A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client stated that he or she will:
*1. Resume full activity level immediately.* 2. Stay in a cool environment when possible. 3. Increase fluid intake for the next 24 hours. 4. Monitor voiding for adequacy of urine output. *rationale* Discharge instructions for the client hospitalized for hyperthermia include prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.
A nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complication of hypothermia blanket use?
1. Frostbite *2. Skin breakdown* 3. Arterial insufficiency 4. Venous insufficiency *rationale* When a hypothermia blanket is used, the skin is inspected frequently for pressure points that over time could lead to skin breakdown. Options 1, 3, and 4 are not complications of hypothermia blanket use.
A nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs more information if the client makes which of the following statements?
1. "Here's the Medic-Alert bracelet I obtained." 2. "I should take my medications an hour before mealtime." *3. "Going to the beach will be a nice, relaxing form of activity."* 4. "I've made arrangements to get a portable resuscitation bag and home suction equipment." *rationale* Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client needs to be aware of the lifestyle changes needed to maintain independence. Taking medications 1 hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should carry medical identification about the condition. The client should avoid activities that could worsen the symptoms, including stress, infection, heat (including staying out of the sun at the beach), surgery, or alcohol.
A nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client states:
1. "I took my pills late last night." 2. "I can hardly think straight today." 3. "I dropped one of my pills on the floor." *4. "I can't swallow very well today."* *rationale* Because dysphagia is a classic sign of myasthenia gravis exacerbation, observing how a client is able to ingest food is an important assessment. Timing of this medication is of paramount concern. Although options 1, 2, and 3 may require further assessment, option 4 reflects the potential of developing myasthenic crisis.
A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse would provide reassurance to the client about the procedure?
1. "You will be able to eat before the procedure unless you get nauseated easily. If so, you should eat lightly." 2. "The MRI machine is a long, hollow narrow tube, and may make you feel somewhat claustrophobic." *3. "Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure."* 4. "It is necessary to remove any metal or metal-containing objects before having the MRI done to avoid the metal being drawn into the magnetic field." *rationale* The MRI scanner is a hollow tube, which gives some clients a feeling of claustrophobia. Metal objects must be removed before the procedure so that they are not drawn into the magnetic field. The client may eat and take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if there is a tendency to get nauseated easily. The client lies supine on a padded table, which moves into the imager. The client must lie still during the procedure. The imager makes tapping noises while scanning. The client is alone in the imager, but the nurse can reassure the client that the technician is in voice communication with the client at all times during the procedure.
The nurse overhears the term "sundowning" used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. The nurse interprets that this client most likely has a diagnosis of:
1. Acquired immunodeficiency syndrome *2. Alzheimer's disease* 3. Parkinson's disease 4. Schizophrenia *rationale* The term "sundowning" or "sundown syndrome" refers to a pattern of disorientation in which the client is more oriented during the daytime hours and more disoriented at night. It is seen often in clients with Alzheimer's disease. It is not a characteristic of the conditions noted in the other options.
A nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?
1. An informed consent is not required. *2. Electrodes will be injected into the skeletal muscles.* 3. Medication is injected into the nerve for stimulation. 4. The client will need to remain nothing per mouth (NPO) for 12 hours before the test. *rationale* EMG involves insertion of needle electrodes into selected skeletal muscles to evaluate changes and electrical potential of the muscles and the nerves that lead to them. The test is useful in evaluating suspected lumbar or cervical disk disease, myasthenia gravis, muscular dystrophy, and other musculoskeletal diseases. The client should be reassured that the needle will not electrocute him or her, and that he or she will experience sensations comparable to an injection as the needles are inserted. An informed consent form is required, and no other special preparation is required for this test.
A client with a spinal cord injury expresses little interest in food, and is very particular about the choice of meals that are actually eaten. The nurse interprets that:
1. Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2. The client has compulsive habits that should be ignored as long as they are not harmful. 3. The client probably has a naturally slow metabolism, and the decreased nutritional intake won't matter. *4. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.* *rationale* Depression is frequently seen in the client with spinal cord injury and may be exhibited as a loss of appetite. The client should be allowed to choose the types of food eaten and to eat as much as is feasible because it is one of the few areas of control that the client has left.
A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which of the following being done by the family?
1. Applying a premolded splint 2. Active ROM to the affected leg 3. Passive range of motion (ROM) to the affected leg *4. Encouraging the client to stand unassisted on the leg* *rationale* The question is worded to elicit an unsafe action on the part of the family. Depending on the client's functional ability, either passive or active ROM is indicated to keep the joint moving freely. Application of a premolded splint would also keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall.
A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should:
1. Ask the family to deliver the care. 2. Leave the client alone until ready to participate. 3. Advise the client that rehabilitation progresses more quickly with cooperation. *4. Acknowledge the client's anger and continue to encourage participation in care.* *rationale* Adjusting to paralysis is difficult both physically and psychosocially for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss, and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence.
A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse would plan which approach as therapeutic in assisting the client to cope with the disease?
1. Assist the client with activities of daily living (ADL) as much as possible. 2. Plan only a few activities for the client during the day. 3. Cluster activities at the end of the day when the client is most bored. *4. Encourage and praise perseverance in exercising and performing ADL.* *rationale* The client with Parkinson's disease tends to become withdrawn and depressed and therefore should become an active participant in his or her own care to prevent this. Activities should be planned throughout the day to inhibit daytime sleeping and boredom. The nurse gives the client encouragement and praises the client for perseverance. Activities such as exercise help prevent progression of the disease, and self-care improves self-esteem.
A client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which of the following activities?
1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously *4. Exhaling during repositioning* *rationale* Activities that increase intrathoracic and intra-abdominal pressures cause indirect elevation of the ICP. Some of these activities include isometric exercises, Valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.
A nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center in the:
1. Cerebrum 2. Cerebellum 3. Hippocampus *4. Hypothalamus* *rationale* Hypothalamic damage causes hyperthermia, which may also be called "central fever." It is characterized by a persistent high fever with no diurnal variation. There is also an absence of sweating. Options 1, 2, and 3 are not associated with temperature regulation.
A nurse is preparing a client who is scheduled to have cerebral angiography performed. The nurse should check the client for:
1. Claustrophobia 2. Excessive weight 3. Allergy to salmon *4. Allergy to iodine or shellfish* *rationale* The client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish. Allergy to salmon is not associated with this procedure. Claustrophobia and excessive weight are areas of concern with magnetic resonance imaging.
A nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the health care provider and reports that the client is exhibiting:
1. Decorticate rigidity 2. Decerebrate rigidity 3. Flaccid quadriplegia *4. Opisthotonos* *rationale* Opisthotonos is a prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation. In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. In decerebrate rigidity, the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are extended stiffly with plantar flexion. The teeth are clenched and the back is hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brain stem.
A nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client?
1. Discouraging the family from touching the client *2. Explaining equipment and procedures on an ongoing basis* 3. Ensuring adherence to visiting hours to ensure the client's rest 4. Encouraging the family not to "give in" to their feelings of grief *rationale* Families often need assistance to cope with the sudden, severe illness of a loved one. The nurse can help the family of an unconscious client by assisting them to work through their feelings of grief. The nurse should explain all equipment, treatments, and procedures, and supplement or reinforce information given by the health care provider. The family should be encouraged to touch and speak to the client and to become involved in the client's care to the extent that they are comfortable. The nurse should allow the family to stay with the client as much as possible, and should encourage them to eat and sleep adequately to maintain their strength.
A nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to read about seizures and related documentation points if the student stated that it is important to document:
1. Duration of the seizure 2. Changes in pupil size or eye deviation 3. Seizure progression and type of movements *4. Client's diet in the 2 hours preceding seizure activity* *rationale* Typically, seizure assessment includes the time the seizure began, part(s) of the body affected, the type of movements and progression of the seizure, changes in pupil size, eye deviation or nystagmus, client condition during the seizure, and postictal status.
A nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:
1. Eating large, well-balanced meals 2. Doing muscle-strengthening exercises 3. Doing all chores early in the day while less fatigued *4. Taking medications on time to maintain therapeutic blood levels* *rationale* Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. It is very important to take medications correctly to maintain blood levels that are not too low or too high. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as well as exposure to heat, crowds, erratic sleep habits, and emotional stress.
A nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which of the following would indicate a basal skull fracture as a result of the injury?
1. Epistaxis 2. Periorbital edema 3. Purulent drainage from the auditory canal *4. Bloody or clear drainage from the auditory canal* *rationale* Bloody or clear watery drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture. This warrants immediate attention. Option 3 is indicative of an infectious process. Options 1 and 2 are not specifically associated with a basal skull fracture.
A nurse is positioning the client with increased intracranial pressure (ICP). Which position should the nurse avoid?
1. Head midline *2. Head turned to the side* 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees *rationale* The head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.
A nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively?
1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side *3. Head of bed elevated 30 to 45 degrees, head and neck midline* 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side *rationale* Following supratentorial surgery, the head of the bed is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This will promote venous return through the jugular veins, which will help prevent a rise in intracranial pressure.
A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of:
1. Heart failure 2. Hypertension *3. Prosthetic valve replacement* 4. Chronic obstructive pulmonary disorder *rationale* The client having an MRI must have all metallic objects removed because of the magnetic field generated by the device. A careful history is done to determine if any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if there is significant risk.
An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 AM. The nurse should first determine which of the following about the client?
1. His insurance status 2. Whether he ate his evening meal 3. Blood toxicology levels *4. Whether this is a change in his usual level of orientation* *rationale* The nurse should first determine whether this is a change in the client's neurological status. The next item to determine should include when the client last ate. Blood toxicology levels may be needed, but the health care provider would prescribe these. Insurance information must be obtained at some point but is not the priority from a clinical care viewpoint.
A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client:
1. In a bed with padded side rails, with limb restraints nearby 2. In a room near the nurses' station, which is near the code cart 3. In a high-Fowler's position, with a nasogastric tube at the bedside *4. In a quiet, dim room with respiratory and cardiac support available* *rationale* Parkinsonian crisis can occur with emotional trauma or sudden withdrawal of medications. The client exhibits severe tremors, rigidity, and bradykinesia. The client also displays anxiety, is diaphoretic, and has tachycardia and hyperpnea. The client should be placed in a quiet, dim room, and respiratory and cardiac support should be available.
A client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid:
1. Is grossly bloody in appearance and has a pH of 6 2. Clumps together on the dressing and has a pH of 7 3. Is clear in appearance and tests negative for glucose *4. Separates into concentric rings and tests positive for glucose* *rationale* Leakage of CSF from the ears or nose may accompany basilar skull fracture. It can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, which is known as the halo sign. It also tests positive for glucose. Options 1, 2, and 3 are not characteristics of CSF.
A nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure?
1. Keeping a supply of suction catheters at the bedside *2. Making sure not to suction for longer than 30 seconds* 3. Auscultating breath sounds to determine the need for suctioning 4. Hyperoxygenating the client before, during, and after suctioning *rationale* Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is present. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently if there is a need. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. The client should not be suctioned for longer than 10 seconds at one time to prevent cerebral hypoxia and an increase in intracranial pressure.
A nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item would be included as part of the precautions?
1. Limiting cigarettes to three per day 2. Allowing out-of-bed activities as tolerated *3. Maintaining the head of the bed at 15 degrees* 4. Allowing one cup of caffeinated coffee per day *rationale* Aneurysm precautions include placing the client on bedrest with the head of the bed elevated in a quiet setting. Lights are kept dim to minimize environmental stimulation. Any activity that increases blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides all physical care to minimize increases in blood pressure. For the same reason, visitors, radio, television, and reading materials are prohibited or limited. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be given.
Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. A nurse monitors the client for effectiveness of this medication, knowing that its primary action is to:
1. Maintain an adequate blood pressure for cerebral perfusion. *2. Decrease cerebrospinal fluid production.* 3. Prevent hyperthermia. 4. Prevent hypertension. *rationale* Acetazolamide is a carbonic anhydrase inhibitor. It is used in the client with, or at risk for, increased intracranial pressure to decrease cerebrospinal fluid production. Options 1, 3, and 4 are not actions of this medication.
An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which of the following is unlikely to be the cause of the client's disorientation?
1. Medication dosage error 2. Hypoglycemia *3. Alzheimer's disease* 4. Impaired circulation to the brain *rationale* Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Medication use, hypoglycemia, and impaired cerebral circulation require evaluation to determine if they play a role in causing the client's current symptoms.
A nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder supports this diagnosis?
1. Muscle wasting *2. Mild clumsiness* 3. Altered mentation 4. Diminished gag reflex *rationale* The initial manifestation of ALS is a mild clumsiness usually in the distal portion of one extremity. The client may complain of tripping and may drag one leg when the lower extremities are involved. Mentation and intellectual function are usually normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations.
A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which of the following?
1. Narrowing of the palpebral fissure *2. A lag in closing the bottom eyelid* 3. A symmetrical smile 4. Paroxysms of excruciating pain in the lips and cheek *rationale* The facial drooping associated with Bell's palsy makes it difficult for the client to close the eye lid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell's palsy. Paroxysms of excruciating pain are seen with trigeminal neuralgia.
A nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse brings which of the following items into the client's room?
1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer *4. Electrocardiographic monitoring electrodes and intubation tray* *rationale* The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmia, which necessitates the use of ECG monitoring. Because the client is immobilized, the nurse should routinely assess for deep vein thrombosis and pulmonary embolism.
A client with myasthenia gravis is experiencing prolonged periods of weakness. The health care provider prescribes a test dose of edrophonium (Enlon) and the client becomes weaker. The nurse interprets this outcome as:
1. Normal 2. Positive 3. Myasthenic crisis *4. Cholinergic crisis* *rationale* Edrophonium is administered to differentiate overdose of medication (cholinergic crisis) from the need for increased medication (myasthenic crisis). Worsening of the symptoms after edrophonium is administered indicates a cholinergic crisis (overdose of the medication), or a negative test.
The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. *Select all that apply.*
1. On the left side 2. With the neck flexed 3. Supine on the left side 4. With extreme hip flexion *5. In a semi-Fowler's position* *6. With the head in a midline position* *rationale* Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.
A nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which of the following measures should the nurse avoid in planning for the client's safety?
1. Padding the side rails of the bed *2. Putting a padded tongue blade at the head of the bed* 3. Placing an airway, oxygen, and suction equipment at the bedside 4. Having intravenous (IV) equipment ready for insertion of IV access *rationale* Seizure precautions may vary somewhat from agency to agency, but they generally have some commonalities. Usually airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client should have an IV access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is no longer best practice and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure will more likely harm the client who bites down during seizure activity. Other risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.
A nurse is caring for a client diagnosed with Bell's palsy 1 week ago. Which of the following data would indicate a potential complication associated with Bell's palsy?
1. Partial facial paralysis *2. Excessive tearing* 3. Negative outcomes on the electromyography 4. The ability to taste food *rationale* Complications of Bell's palsy include abnormal return of nerve function; "crocodile tears" (autonomic fibers reconnect to the lacrimal duct instead of the salivary glands, so the client develops excessive tearing while eating); abnormal facial movements because of reinnervation of inappropriate muscles; and spasms, atrophy, and contractures caused by incomplete motor fiber reinnervation. Partial facial paralysis is a factor indicating recovery. Negative outcomes on the electromyography performed 1 week after symptom onset indicate that nerve function is present (a negative test indicates a positive prognostic outcome). Tasting food 1 week after symptom onset indicates a good prognosis for recovery.
A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will:
1. Wear the patch for 1 hour at a time. *2. Wear the patch continuously, alternating eyes each day.* 3. Wear the patch continuously, alternating eyes each week. 4. Use the patch only when vision is especially troublesome. *rationale* Placing an eye patch over one eye in the client with diplopia removes the second image and restores more normal vision. The patch is worn continuously and is alternated on a daily basis to maintain the strength of the extraocular muscles of the eyes.
A nurse has instructed the family of a brain attack (stroke) client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will:
1. Place objects in the client's impaired field of vision. 2. Discourage the client from wearing own eyeglasses. 3. Approach the client from the impaired field of vision. *4. Remind the client to turn the head to scan the lost visual field.* *rationale* Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and performs client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
A nurse is administering mouth care to an unconscious client. The nurse should avoid doing which of the following?
1. Positioning the client on the side *2. Using products with lemon or alcohol* 3. Brushing the teeth with a small toothbrush 4. Cleansing the mucous membranes with Toothettes *rationale* The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily using a small toothbrush. The gums, tongue, roof of mouth, and oral mucous membranes are cleansed with Toothettes to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with lemon or alcohol should be avoided, because they have a drying effect.
A nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure?
1. Prone in semi-Fowler's position 2. Supine with a pillow under the head *3. Prone with a pillow under the abdomen* 4. Lateral with the head slightly higher than the rest of the body *rationale* For 1 hour after the procedure, the client assumes a prone position if able with a pillow under the abdomen to increase intra-abdominal pressure. This position retards leakage of cerebrospinal fluid. The remaining options do not accomplish this and so are incorrect.
A nurse is assisting with caring for a client after a craniotomy. The nurse plans to position the client in a:
1. Prone position 2. Supine position *3. Semi-Fowler's position* 4. Dorsal recumbent position *rationale* After a craniotomy, the head of the bed is elevated 30 to 45 degrees (semi-Fowler's to Fowler's position), and the client's head is maintained in a midline, neutral position to facilitate venous drainage. Options 1, 2, and 4 are incorrect positions.
An adult client has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. The nurse checks for which of the following negative values if the CSF is normal?
1. Protein 2. Glucose 3. White blood cells *4. Red blood cells* *rationale* The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0 to 3/mm3). Protein (15 to 45 mg/dL) and glucose (40 to 80 mg/dL) are normally present in CSF.
A nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client?
1. Providing sensory cues 2. Giving simple, clear directions 3. Providing a stable environment *4. Encouraging multiple visitors at one time* *rationale* Clients with cognitive impairment from neurological dysfunction respond best to a stable environment, which is limited in the amounts and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion and agitation can be minimized by reducing environmental stimuli (such as television, multiple visitors) and keeping familiar personal articles (such as family pictures) at the bedside.
A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which of the following to determine whether the client is ready to begin sitting up?
1. Puts both of the client's hip joints through full range of motion *2. Compares the client's pulse and blood pressure when both flat and sitting* 3. Loosens the vest to gather data on the client's ability to support his own trunk 4. Inspects the halo vest pin sites to monitor for purulent drainage, redness, and pain *rationale* Clients with cervical spinal cord injuries may lose control over peripheral vasoconstriction, causing postural (orthostatic) hypotension when upright. A drop of 15 mm Hg in the systolic pressure or 10 mm Hg in the diastolic pressure accompanied by an increase in heart rate when the head is elevated may indicate autonomic insufficiency that can cause dizziness or syncope in the upright position. Assessment of skin integrity of the pin sites is important but does not affect sitting readiness. Hip range of motion is not affected initially in this type of cord injury. The halo vest is not loosened by the nurse. The vest provides trunk stability for sitting.
A nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will:
1. Sit in soft, deep chairs. 2. Exercise in the evening to combat fatigue. *3. Rock back and forth to start movement with bradykinesia.* 4. Buy clothes with many buttons to maintain finger dexterity. *rationale* The client with Parkinson's disease should exercise in the morning, when energy levels are highest. The client should avoid sitting in soft, deep chairs because getting up from them can be difficult. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to allow for easier dressing.
A client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety?
1. Speak loudly to the client. 2. Test the temperature of the shower water. 3. Check the temperature of the food on the dietary tray. *4. Provide a clear path for ambulation without obstacles.* *rationale* Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Testing the shower water temperature would be useful if there were impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior one third of the tongue, respectively.
A nurse is trying to communicate with a brain attack (stroke) client with aphasia. Which action by the nurse would be least helpful to the client?
1. Speaking to the client at a slower rate 2. Allowing plenty of time for the client to respond *3. Completing the sentences that the client cannot finish* 4. Looking directly at the client during attempts at speech *rationale* Clients with aphasia after stroke often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse should avoid shouting (because the client is not deaf), appearing rushed for a response, and completing responses for the client.
A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity?
1. Squeezing rubber balls 2. Doing push-ups in a prone position 3. Extending the arms while holding weights *4. Doing active range of motion to finger joints* *rationale* Range-of-motion exercises of the finger joints prevent contractures but do not actively strengthen muscle groups needed for self-mobilization with paraplegia. Other activities that are more effective include push-ups from a prone position, sit-ups from a sitting position, extending the arms while holding weights, and squeezing rubber balls or crumpling newspaper.
A client with spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of recurrence?
1. Strict adherence to a bowel retraining program 2. Keeping the linen wrinkle-free under the client 3. Avoiding unnecessary pressure on the lower limbs *4. Limiting bladder catheterization to once every 12 hours* *rationale* The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be performed every 4 to 6 hours, and Foley catheters should be checked frequently for kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
Which clinical manifestation is observed in the clonic phase of a seizure?
1. Sudden loss of consciousness 2. Brief flexion of the extremities *3. Extension spasms of the body* 4. Body stiffening *rationale* The clonic phase of a seizure is characterized by violent extension spasms of the entire body interrupted by muscular relaxation and accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. There is excessive salivation resulting in frothing from the mouth, biting of the tongue, profuse sweating, and a rapid pulse. The clonic jerking subsides by slowing in frequency and losing strength over a period of 30 seconds. Options 1, 2, and 4 identify the tonic phase of a seizure.
A nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which of the following is noted?
1. Sudden tachycardia 2. Pallor of the face and neck *3. Severe, throbbing headache* 4. Severe and sudden hypotension *rationale* The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.
A nurse is assisting the health care provider in performing a lumbar puncture. The nurse prepares for the procedure by placing the client in which position?
1. Supine 2. Prone 3. Lateral *4. Fetal position* *rationale* The client is assisted into a fetal position at the edge of the bed with the knees drawn up to the chest. This position allows full flexion of the spine and wider spaces between the vertebrae. The nurse should also place a pillow between the client's legs to prevent the upper leg from rolling forward and a small pillow under the client's head to support the spine in a horizontal position.
A client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure?
1. Supine, in semi-Fowler's 2. Prone, in slight Trendelenburg's 3. Prone, with a pillow under the abdomen *4. Side-lying, with legs pulled up and head bent down onto the chest* *rationale* The client undergoing LP is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae.
A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client?
1. Taking the temperature 2. Observing for dyskinesias *3. Monitoring the respiratory rate* 4. Checking extremity muscle strength *rationale* Because compromise of respiration is a leading cause of death in cervical spinal cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is assured. Dyskinesias occur in cerebellar disorders, so are not important in cord-injured clients, unless a head injury is suspected.
A nurse is assisting in caring for a client with a supratentorial lesion. The nurse monitors which of the following as the critical index of central nervous system (CNS) dysfunction?
1. Temperature 2. Blood pressure 3. Ability to speak *4. Level of consciousness* *rationale* Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client level of consciousness is the most critical index of CNS dysfunction.
A client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse would plan on leaving the cervical collar in place until:
1. The family comes to visit. 2. The nurse needs to do physical care. *3. The result of spinal x-rays is known.* 4. The health care provider makes rounds. *rationale* There is a significant association between cervical spine injury and head injury. For this reason, the nurse leaves any form of spinal immobilization in place until lateral cervical spine x-rays rule out fracture or other damage.
A nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad, because "his feet are always cold at night." The nurse should incorporate which of the following concepts when formulating a response to the family member?
1. The resident has a right to procure and keep his own property. 2. Heating pads are dangerous and are likely to cause fires. *3. Older adults often have slower neurological response times and are therefore more at risk for burns.* 4. The long-term care facility strictly prohibits the use of heating pads. *rationale* Age-related changes in the older adult make the client more at risk for burns as a result of slower neurological response times. Option 1 ignores the client's safety and is unrelated to the subject of the question. Option 2 represents a general statement, but does not pertain to the individual safety of this client. Option 4 represents a bureaucratic response, and does not consider client needs.
A nurse is caring for a client scheduled for magnetic resonance imaging (MRI). Which instruction does the nurse reinforce to the client?
1. The test will require that a dye be injected. 2. Fluids and food are restricted for 12 hours before the test. *3. Earplugs can be worn if the noise from the machine is uncomfortable.* 4. The test may cause some pain, but pain medication will be prescribed if pain occurs. *rationale* The client is informed that the MRI is painless and requires no dye or radiation, and that there are no dietary restrictions. The nurse informs the client that the MRI may damage credit cards and watches and that jewelry and hair clips cause artifacts. These objects should be removed before the test. The client is prepared for the beating noise of the MRI machine and is reassured that earplugs may be used if the noise is uncomfortable.
Which data collection finding supports the possible diagnosis of Bell's palsy?
1. Tingling sensations of the eyelid, in addition to decreased lacrimation 2. Stabbing facial pain with intermittent tingling sensations in the eyes *3. Speech or chewing difficulties accompanied by facial droop* 4. Burning pain in the nose with intermittent facial paralysis *rationale* Bell's palsy is a one-sided facial paralysis from compression of the facial nerve, CN VII. There is facial droop from paralysis of the facial muscles, increased lacrimation, and speech or chewing difficulty. The remaining options are not characteristics of Bell's palsy.
A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has precipitating factors such as:
1. Too little exercise *2. Omitted doses of medication* 3. Increased doses of medication 4. Decreased intake of fatty foods *rationale* Myasthenic crisis is often caused by undermedication and responds to administration of cholinergic medications such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect options. Overexertion and overeating could trigger myasthenic crisis.
A nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further clarification of the instructions if the client states that he or she will:
1. Use a straw for drinking. *2. Drive only during the daytime.* 3. Use caution, because the device alters balance. 4. Wash the skin daily under the lamb's wool liner of the vest. *rationale* The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest or the device to protect the skin from ulceration and should use powder or lotions sparingly or not at all. The wool liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client should not drive because the device impairs the range of vision.
A client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should avoid which of the following when planning care for this client?
1. Using a Stryker frame bed *2. Removing the weights to reposition the client* 3. Assessing the integrity of the weights and pulleys 4. Comparing the amount of prescribed traction with the amount in use *rationale* Crutchfield tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until radiography reveals that the vertebral column is realigned. Weights then may be gradually reduced to a point that maintains alignment. The client with Crutchfield tongs is placed on a Stryker frame or Roto-Rest bed. The nurse ensures that weights hang freely and the amount of weight matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys. The nurse does not remove the weights to administer care.
A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration?
1. Using adult diapers 2. Inserting a Foley catheter *3. Establishing a toileting schedule* 4. Padding the bed with an absorbent cotton pad *rationale* A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. A Foley catheter should be used only when necessary because of risk of infection. Use of diapers or pads is the least acceptable alternative because the risk of skin breakdown exists.
A client was seen and treated in the emergency department for treatment of a concussion. The nurse determines that the family needs further discharge instructions if they say to bring the client back to the emergency department if which of the following occurs?
1. Vomiting *2. Minor headache* 3. Difficulty speaking 4. Difficulty awakening *rationale* A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the health care provider or return the client to the emergency department if certain signs and symptoms are noted. These include confusion, difficulty awakening or speaking, one-sided weakness, vomiting, or severe headache. Minor headache is expected.
