Neuro Practice Quiz
The son of a client diagnosed with ALS asks the nurse, "Is there any chance that I could get this disease?" Which statement by the nurse would be most appropriate?
"ALS does have a genetic factor and runs in families."
Which statement by the female client indicates that the client understands factors that may precipitate seizure activity?
"I am going to take a class in stress management."
A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam (Valium) 0.25 mg/kg. How many milligrams will be given to this client?
15 mg
A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, which deficits are anticipated?
A delayed reaction in response because of the interrupted impulses from the central nervous system
A client is admitted for scheduled gamma-knife radiosurgery in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client?
Assess neurological findings
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
Ease the client to the floor
A client, who was adopted at birth, recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears?
Encourage client to verbalize fears.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medicalsurgical unit. Which task should not be assigned to the UAP?
Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing
A client with a neurologic deficit has been admitted to the nursing unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately?
Report the change to the physician.
The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak?
Residents of a college dormitory
The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement?
Teach the client to direct food and fluid toward the right side.
The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?
Tell the UAP to stop trying to insert anything in the mouth.
The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process?
The client will be able to carry out activities of daily living
The nurse is caring for several clients on a medical unit. Which client should the nurse assess first?
The client with pneumonia who has a pulse oximeter reading of 90%.
The nurse is caring for clients on a neurologic floor. Which client goal is most appropriate for the acute phase of a neurologic injury?
The client's vital signs will stabilize returning to baseline.
The nurse is caring for a client in the emergency department with diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. For which action, made by the nurse aide, would the nurse provide further instruction?
The nurse aide moved the client's head to clean behind the ears.
The nurse is talking with a newly paralyzed client and his wife. The wife is trying to raise the client's spirits and begins talking about the possibility of them having a baby. When the wife is alone, which instruction in essential?
There is a reduced ability for your husband to be able to father children.
Which statement best describes the scientific rationale for alternating a nonnarcotic antipyretic and a nonsteroidal anti- inflammatory drug (NSAID) every two (2) hours to a female client diagnosed with bacterial meningitis?
This regimen helps to decrease the purulent exudate surrounding the meninges
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?
brain tumor
A client presents to the emergency department status post seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client?
lumbar puncture
What phase of a neurologic deficit begins when the client's condition is stabilized?
recovery
The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority?
Include client in planning of care and setting of goals.
The client is in the terminal stage of ALS. Which intervention should the nurse implement?
Perform passive ROM every two (2) hours
Which neurons transmit impulses from the CNS?
A. motor
The nurse is admitting the client for ruleout encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply.
Ask the client if he or she has had a cold in the last week. Ask the client if he or she has had a cold in the last week. Determine if the client has recently received any immunizations
The nurse is assisting in the discharge process where a female, paralyzed client is returning home with her husband and two children. Which of the following prescription classifications, used prior to hospitalization, is most important to relate to the physician when discharging?
Birth control pills
The nurse is employed in a neurologist's office, performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?
CN VIII
The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response?
Observing the client's response to painful stimulus
The nurse is caring for a 55-year-old client on a rehabilitated unit following a cerebrovascular accident (CVA). The nurse is instructing on range-of-motion exercises when the client begins to cry. The client states she has always taken care of the family and does not want to be a burden. Which nursing diagnosis would the nurse add to the plan of care?
Ineffective Role Performance related to inability to function in family role
The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct?
"The client may be experiencing a change in affect due to the brain injury."
The public health department nurse is preparing a lecture on prevention of West Nile virus. Which information should the nurse include?
Change water daily in pet dishes and birdbaths
The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe?
Clustering many nursing activities
The nurse is caring for a post-lumbar puncture client experiencing an intense headache. The physician is notified and arriving to assess the client. If the physician chooses aggressive treatment, which nursing action is anticipated?
Drawing venous blood to perform a blood patch
The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an experimental therapy?
Fetal tissue transplantation.
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside?
Intubation tray and suction apparatus
The nurse is caring for an 82-year-old client who needs bladder training. The nurse knows that bladder training is difficult for older adult clients with neurologic deficit because of what?
Relaxation of the internal bladder sphincter
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
Report any febrile illness
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data?
When, if any, was your last narcotic use?
The nurse is caring for clients on a medical surgical floor. Which clients should be assessed first?
The 58-year-old client diagnosed with Parkinson's disease who is crying and worried about her facial appearance.
The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit?
The client will be able to perform three (3) ADLs with assistance.
The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem "altered cerebral tissue perfusion"?
The client will be protected from injury if seizure activity occurs
The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis?
Weakness and paralysis
The nurse is instructing the client on how to perform Credé's maneuver. In which situation is this maneuver helpful?
When a client is attempting to empty the bladder
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?
"I will brush my teeth after every meal."
The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions?
"I will schedule appointments late in the morning after his morning bath."
The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse?
"It is a bacterial infection of the tissues that cover the brain and spinal cord."
The client diagnosed with ALS asks the nurse, "I know this disease is going to kill me. What will happen to me in the end?" Which statement by the nurse would be most appropriate?
"Most people with ALS die of respiratory failure."
The home care nurse is evaluating a post-cerebrovascular accident (CVA) client 1 week after returning to the home from a rehabilitation setting. Which of the following statements, made by the client, most concerns the nurse?
"My spouse goes to work in the morning and leaves my lunch at my bed stand."
The client with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding?
A residual of 125 mL.
The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care?
Administer antibiotics
Which problem is the highest priority for the client diagnosed with West Nile virus?
Altered tissue perfusion
he client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement?
Assist the client to prepare an advance directive.
The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly?
Cerebral Vascular Accident (CVA, stroke).
The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis?
Crackles in the upper lung fields and jugular vein distention.
Which type of precautions should the nurse implement for the client diagnosed with septic meningitis?
Droplet Precautions
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
Elevate the head of the bed.
Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field?
Ensure a clutter-free walkway
The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply.
Have anticonvulsant medication serum levels checked regularly. Keep a record of seizure activity Avoid over-the-counter medications
The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor?
Headache, vomiting, and papilledema
The nurse is caring for a client with paraplegia in the acute care setting. The client's last bowel movement was 4 days ago. Which nursing action is best to assist the client in accomplishing the goal of an enema?
Instill the mini enema slowly (1 to 2 oz at a time) followed by a waiting period.
The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which pre procedure teaching should the nurse implement?
Instruct the client to stay awake for 24 hours prior to the EEG
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
Moving the head and chin toward the chest
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?
Neurovascular system
The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first?
Note the first thing the client does in the seizure
When a nurse is caring for a client diagnosed with neurologic deficit who has begun responding to those around him, what therapy should the nurse suggest to help strengthen muscles that are under voluntary control?
Occupational therapy
The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care?
Offer six (6) meals per day with a soft consistency
A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?
Position the client flat for at least 3 hours.
The nurse caring for a client in the chronic phase of a neurologic deficit knows that nursing management focus on what?
Preventing physical and psychological complications
Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply.
Purpura of hands and feet Cloudy cerebral spinal fluid
The nurse is assessing the client diagnosed with meningococcal meningitis. Which assessment data would warrant notifying the HCP?
Purpuric lesions on the face
The nurse is assessing a client's ability to detect sensation in the upper extremity. Which nursing actions would be appropriate? Select all that apply.
Touch the client with the pads of the finger. A gentle pinch using the fingers. Drag the alcohol pad over the skin. Place a warm cotton ball on the arm.
A client with increased intracranial pressure is receiving mannitol via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment?
Urine output is increased
The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client?
Vector bites
The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of conscious should the nurse document?
somnolent (lethargic)
The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness?
somnolent (lethargic)
The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care?
"Clients and families are the focus of hospice care."
The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?" The nurse is most helpful to say which of the following?
"Grief is a normal process. Let's discuss offering support throughout the process."
A client is brought to the emergency department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other conditions are considered neurologic deficits? Select all that apply.
Abnormal bladder elimination Paralysis Impaired speech
The client is admitted to the intensive care unit (ICU) wxperiencing status epilepticus. Which collaborative intervention should the nurse anticipate?
Administer an anticonvulsant medication by intravenous push.
The client diagnosed with septic meningitis is admitted to the medical floor at noon. Which health-care provider's order would have the highest priority?
Administer an intravenous antibiotic
Which collaborative intervention should the nurse implement when caring for the client with West Nile virus?
Administer intravenous fluids while assessing for overload
In which of the following disease processes is the nurse most likely to care for a client in the chronic phase of a neurologic disease?
Alzheimer's disease
The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications?
Carbidopa makes more levodopa available to the brain.
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?
Cerebrospinal fluid is cloudy in nature.
Which assessment finding would the earliest and most sensitive indicator that there is an alteration in intracranial regulation?
Change in level of consciousness
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?
Damage to the nerves that facilitate vision and hearing
The client diagnosed with Parkinson's disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data?
Difficulty swallowing and immobility
The nurse is working in an outpatient studies unit administering neurologic tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. The nurse is most correct to state which?
The paste is removed with standard shampoo.
The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse the health-care provider to order for the significant others in the home?
Antimicrobial chemoprophylaxis
The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority?
Assess level of consciousness
The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication?
Assess level of consciousness.
A nurse is completing a neurologic assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?
occipital
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.
pinpoint pupils absence of pupillary response unequal pupils
The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make?
social worker
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds
A client that the nurse is caring for experiences a seizure. What would be a priority nursing action?
Protect the client from injury.
A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?
"My children are at greater risk to develop this disease."
The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response?
"Some people have a warning that the seizure is about to start."
The male client diagnosed with a brain tumor is scheduled for a magnetic resonance imaging (MRI) scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response?
"You're scared. Tell me about what is scaring you."
The client is to receive a 100-mL intravenous antibiotic over 30 minutes via an intravenous pump. At what rate should the nurse set the IV pump? ___________
200 mL
A client undergoes a scheduled electroencephalogram (EEG). Which of the following post-procedure activities should the nurse carry out for the client?
Allow the client to rest and shampoo the client's hair
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?
An absence seizure
The nurse preparing to care for a patient after a suspected stroke would question which order?
Antihypertensive
The client has been diagnosed with a brain tumor. Which presenting signs and symptoms help to localize the tumor position?
Bradykinesia and scanning speech
The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?
CN XII
The client is diagnosed with ALS. Which client problem would be most appropriate for this client?
Disuse syndrome.
Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply
Encourage the client to increase fluids Assess for deep vein thrombosis (DVT). Turn the client every two (2) hours Assess for any alterations in elimination.
The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement?
Ensure that helmets are worn in appropriate areas
The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client?
Explaining hospice care and services
An emergency department nurse is admitting a client brought in by the paramedics after falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client?
Goal is to stabilize the client and prevent further neurologic damage.
What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurologic deficit?
Help the client to the bathroom at a particular time each day.
A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client?
Hopelessness
The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?
Increased intracranial pressure
Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?
Lethargy
The nurse is instructing the paralyzed client on a method to stimulate the relaxation of the urinary sphincter aiding in urinary elimination. Which instruction would be correct?
Lightly massage or tap the skin above the pubic area.
Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease?
Maintaining a safe environment
Which of the following assessment tools should the nurse use to perform a neurologic assessment?
Mini-Mental Status Examination
The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan?
Monitor the client's respirations frequently
The client is switched to a different dose of carbidopa-levodopa. Which nursing assessment is primary during this time of medication change?
Monitor vital sign fluctuation.
Which diagnostic test is used to confirm the diagnosis of Amyotropic Lateral Sclerosis (ALS)?
Muscle biopsy
The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply.
Place the client in a side-lying position with the back arched. Have the client empty the bladder prior to the procedure. Explain to the client what to expect during the procedure.
The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis?
Positive Kernig's sign and nuchal rigidity
Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident?
Prevention of joint contractures
The nurse is caring for a client with neurologic deficits who is interested in implementing a bowel training program. Which of the following does the nurse identify as the first step?
Recording bowel movements
The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline with carbidopa-levodopa to the medication regime should result in which purpose?
Slows the progression of the disease
Which of the following occupations are anticipated to improve the functioning of a client with a neurologic deficit? Select all that apply.
Speech therapist Occupational therapist Physical therapist Neurologist
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?
Suicidal ideations
The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse is correct to instruct on the action of which system?
Sympathetic nervous system
The nurse is caring for a client newly diagnosed with multiple sclerosis. The client indicates that there is so much to understand at one time. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. Which nursing action is correct?
Tell the client that the covering is called myelin and that can be discussed at the next meeting.
The client admitted to the hospital to rule out encephalitis is being prepared for a lumbar puncture. Which instructions should the nurse teach the client regarding care postprocedure?
Tell the client to increase fluid intake to 300 mL for the next 48 hours.
The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, "Why not try chemotherapy first? It has helped my other tumors." The nurse's response is based on which scientific rationale?
The blood-brain barrier prevents medications from reaching the brain.
The nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse?
The client becomes lethargic and is difficult to arouse using verbal stimuli
The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?
The client grasps the affected arm at the wrist and raises it.
The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery?
The client has an intake of 1,000 mL and an output of 3,500 mL
The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client's condition is becoming worse?
The client has become flaccid and does not respond to stimuli.
Which rationale explains the transmission of the West Nile virus?
Transmission occurs through exchange of body fluids when sneezing and coughing
The brain stem holds the medulla oblongata. What is the function of the medulla oblongata?
Transmits motor impulses from the brain to the spinal cord
A nursing instructor is teaching the senior nursing class about clients with neurologic disorder. The instructor tells the students that these clients are at risk of disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. What nursing intervention helps prevent plantar flexion?
Use of a footboard
The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate to the nurse that the client is in a semi comatose state?
a score of 9
A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?
flaccidity
The nurse is caring for a client in the neurologic intensive care unit. The nurse is noting from the assessment findings that the client is lacking a connection because motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit?
medulla oblingata
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?
muscle spasm
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?
Administer medications at exact intervals ordered.
The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first?
Administer oxygen via nasal cannula
The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?
Allergic reaction to the imaging material
Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply.
elevated systolic blood pressure wide pulse pressure
A home health nurse is assisting the wheelchair-dependent, post-cerebrovascular accident client in transition from the rehabilitative center to home. Which of the following concerns would the nurse address first when assessing the client's home?
Steps to the front door
When using pharmacologic aids to assist with bowel training, which aid would the nurse anticipate to be used first?
Stool softener
After shunt procedure, the nurse would monitor the patient's neurologic status by using which test?
Stroke Scale Glasgow Coma Scale
A critical care nurse is documenting her assessment of a client she is caring for. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean?
The client is not responding to stimuli.
The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client?
The client will regain as much neurological function as possible
The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated?
antihistamine
The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
cerebral angiography
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
Mannitol
Which is a common cognitive problem associated with Parkinson's disease?
Memory deficits.
The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion?
The client may have rapid mood swings and become easily upset
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
The client will remain free of injury if a seizure does occur.
The client is waiting in a triage area to learn the medical status of his family following a motor vehicle accident. The client is pacing, taking deep breaths, and wringing the hands. Considering the effects in the body systems, what effects does the nurse anticipate in the liver?
The liver will convert glycogen to glucose for immediate use.
The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?
comatose
When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings?
Hypertension and bradycardia
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?
Drooping eyelids
A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct?
Have the client close his eyes and stand erect.
The charge nurse is making assignments. Which client should be assigned to the new graduate nurse?
The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes.
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
Seizure was 1 minute in duration including tonic-clonic activity.
Which nursing technique best allows the client with slight expressive aphasia to communicate his feelings about using adaptive equipment in public?
Sit beside client and patiently assist in interpreting communication.
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
Turn client to side-lying position.
The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?
Turn the client to the side and allow the client to sleep.
Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy?
Use ophthalmic lubricant and protect the eye.
The nurse should teach a patient that which is a primary prevention strategy to reduce the occurrence of head injuries?
Violence prevention
Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area?
computed tomography
The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord?
second lumbar vertebrae
