Neuro study set 1
A nurse is assisting in caring for a client with a suspected diagnosis of meningitis. The nurse reinforces to the client information regarding which diagnostic test that is commonly used to confirm this diagnosis?
1. White blood cell (WBC) count 2. Lumbar puncture 3. Serum electrolytes 4. Urine culture ANS:2
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." ANS:2
What assessments are included in the four score com scale? select all that apply
1. Eye response 2. Motor response 3. Brainstem reflexes 4. Respiration 5. Verbal response ANS: 1,2,3,4
A patient who has had a generalized tonic-clonic seizure is sound asleep 30 minutes after the seizure. Meals are about to be delivered. Which nursing action is most appropriate?
1. Wake the patient because nourishment is essential following a seizure 2. Wake the patient to do a neurologic assessment before the meal 3. Let the patient sleep during the postictal state, and keep the meal warm 4. Do not attempt to wake the patient because of the risk of a repeat seizure ANS: 3
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 ANS:2
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 ANS:4
A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which of the following signs and symptoms? Select all that apply.
1. Diarrhea 2. Tinnitus 3. Tachycardia 4. Photophobia 5. Red, macular rash 6. Positive Kernig's sign ANS:3,4,5,6
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 ANS:2
A nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. The nurse assists in developing a plan of care, knowing that which of the following is a characteristic of early Alzheimer's disease?
1. Confusion 2. Forgetfulness 3. Wandering 4. Personality changes ANS:2
A nurse is caring for a client scheduled for a cerebral angiogram with contrast dye. Which of the following client responses should the nurse communicate tot eh provider? (Select all that apply.) ___ "I may be pregnant." ___ "I take Coumadin." ___ "I am on an antihypertensive." ___ "I am allergic to shellfish." ___ "I am allergic to latex."
"I may be pregnant." "I take Coumadin." "I am allergic to shellfish."
A patient with a newly diagnosed seizure disorder is being prepared for discharge. What medication does the nurse anticipate the patient being discharged on to prevent recurrent seizures?
Gabapentin.
The client with PD is taking benztropine mesylate and should report what side effect?
Inability to urinate
A patient with meningitis has photophobia and a severe headache. Which nursing interventions will be most helpful to relieve symptoms?
1. Administer antibiotics as ordered, and prepare patient for a lumbar puncture 2. Darken the room and administer analgesics 3. Administer acetaminophen as ordered and maintain isolation 4. Check level of consciousness with the GCS and monitor VS ANS: 2
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 ANS:1
A patient has returned from having a CT scan with contrast. Which of the following should be a priority in the hours after the scan?
1. Ambulation 2. Drinking fluids 3. Turning side to side 4. Coughing and deep breathing ANS: 2
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 ANS:4
The nurse knows the patient understands teaching about an angiogram when the patient makes which of the following statements?
1. A small needle will be inserted into my spinal column to withdraw fluid for examination 2. I will be in a large machine that uses magnetic energy to create images; it has a noisy knocking sound 3. Electrodes will be placed on my head to monitor electrical activity in my brain 4. A catheter will be placed in an artery in my groin, and dye will be injected that will make vessels show up on x-ray ANS: 4
A nurse is reinforcing teaching to an older adult client who has AD and his wife. The client has been prescribed donepezil (Aricept). Which of the following statements by his wife indicates an understanding of the teaching about the medication? (Select all that apply.) ___ "It should be taken in the morning before breakfast." ___ "It should increase my husband's appetite. ___ "It should help my husband sleep better." ___ "It may cause diarrhea." ___ "It should help my husband's daily function.
"It may cause diarrhea." "It should help my husband's daily function."
The client has just undergone CT scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?
1. "I should drink extra fluids for the remainder of the day." 2. "I should not take any medication for at least 4 hrs" 3. "I should eat lightly for the remainder of the day." 4. "I should rest quietly for the remainder of the day" ANS: 1
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. ANS:4
Which of the following is a symptom of ICP that should be reported immediately to the primary care provider?
1. Constricted pupils 2. Decreasing LOC 3. Narrowing pulse pressure 4. Bradypnea ANS: 2
Which nursing interventions are appropriate for the patient with a neurodegenerative disorder who has difficulty swallowing?
1. Have a patient tuck his or her chin down during swallowing 2. Provide clear to full liquids; avoid solid foods 3. Place the patient in semi-Fowler's position for eating 4. Provide adaptive eating utensils ANS: 1
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 ANS:3
What are the normal effects of aging on the CNS? Select all that apply
1. Increased postural stability 2. Reduced blood flow to the brain 3. Impaired short term memory 4. Sleep disturbances 5. Loss of deep tendon reflexes 6. Decrease in acetylcholine ANS: 2,3,4,6
Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which s/s indicates the client is experiencing an adverse effect?
1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements ANS: 4
A resident of an extended care facility who has AD is sitting in a corner, crying loudly that no one is paying attention. Several staff members have tried to find out whats wrong, but the patient won't answer, and just keeps rocking back and forth and crying. Which approach by the nurse might best help the patient?
1. Say in a quiet voice, "what is wrong? We can't help you if you don't tell us what's wrong" 2. Sit quietly by the patient and say, " I'm here; you aren't alone" 3. Say in a firm voice, "several staff members have asked what you need. Now it is time to stop crying" 4. Ignore the continued crying. Continuing to respond will encourage the behavior ANS: 2
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 ANS:4
Ibuprofen (Advil) is prescribed for a client. Which instruction should the nurse give the client about taking this medication?
1. Take with 8 oz of milk 2. Take in the morning after arising 3. Take 60 mins before breakfast 4. Take at bedtime on an empty stomach ANS: 1
The nurse is collecting data bout a child who has been admitted to the hospital with a diagnosis of seizures. Which action would best assist in determining the causes of the seizures?
1. Testing the child's urine for specific gravity 2. Asking the child what happens during a seizure 3. Obtaining a family history of psychiatric illness 4. Obtaining a history regarding factors that may occur before the seizure activity ANS:4
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. ANS:3
A client had a crani 3 days ago, what would indicate the possible development of meningitis?
A positive Brudzinski sign
A nurse is reinforcing teaching with a client who is to undergo an EEG the next day. Which of the following information should the nurse include in the teaching?
A. "Do not wash your hair the morning of the procedure" B. "Try to stay awake most of the night prior to the procedure" C. "The procedure will take approximately 15 minutes" D. "You will need to lie flat for 4 hours after the procedure" ANS: B
A nurse is collecting data from a client who reports severe headache and a stiff neck. Data collection reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?
A. Administer antibiotics B. Implement droplet precautions C. Obtain an IV access D. Decrease bright lights ANS: B
A nurse is caring for a client who is to start therapy with bromocriptine (Parlodel). For which of the following should the nurse monitor? (Select all that apply.)• A. Dyskinesias B. Orthostatic hypotension C. Insomnia D. Constipation E. Darkened urine
A. Dyskinesias B. Orthostatic hypotension D. Constipation
he client has been prescribed bromocriptine (Parlodel) to obtain better management of the muscular rigidity. Which of the following instructions should the nurse give the client to manage a common side effect of bromocriptine? A. Rise slowly when standing up. B. Increase dietary fiber and fluid intake. C. Chew sugarless gum for dry mouth. D. Wear sunscreen when outdoors.
A. Rise slowly when standing up.
A health department nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include?
A. The vaccine reduces the risk of respiratory infection B. Administer the vaccine in a series of four doses C. Recommend this vaccine for adolescents before starting college D. The vaccine series begins at 2 months of age ANS: C
A nurse is reinforcing teaching with the family of a client who has PD and a new prescription for bromocriptine. Which of the following statements by a family member should the nurse identify as understanding of the teaching?
A. This medication can cause dizziness B This medication turns into dopamine once in the brain C. We should see improved mobility in 2 to 3 days D. We should avoid dopaminergics while taking this medication ANS: A
A family member of a client who ahs Alzheimer's disease (AD) asks the nurse about risk factors for AD. The nurse should inform the family member that which of the following are risk factors for AD? (Select all that apply.) ___ Age ___ Family history ___ Smoking ___ Sun exposure ___ Previous head injury
Age Family history Previous head injury
A nurse in a provider's office is reinforcing teaching for a client who has a seizure disorder. Which of the following should the nurse include in the teaching? (Select all that apply.) ___ Bathe in the tub instead of taking a shower. ___ Avoid drinking alcohol. ___ Avoid environments with flashing lights. ___ Wear identification indicating the presence of a seizure disorder. ___ Avoid foods that are high in purine.
Avoid drinking alcohol. Avoid environments with flashing lights. Wear identification indicating the presence of a seizure disorder.
A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following should the nurse include? A. Do not wash your hair in the morning of the procedure. B. You will be given an analgesic prior to the test. C. The procedure will take approximately 15 min. D. You will need to lie flat for 4 hr after the procedure
B. You will be given an analgesic prior to the test.
A nurse is caring for a client with meningitis. Which of the following findings during data collection should the nurse immediately report to the provider? A. Fever B. Report of photophobia C. Duskiness of nail beds of fingers D. Restlessness
C. Duskiness of nail beds of fingers
Scenario: A nurse is assisting an RN admit a client who is diagnosed with bacterial meningitis from Neisseria meningitidis. Which of the following isolation precautions should the nurse implement to prevent transmission of the disease? A. Wear gloves upon entering the room. B. Place the client in a room with negative airflow exchanges. C. Wear a mask when standing at the bedside of the client. D. Place an N-95 HEPA filter mask on the client when transportation outside the room occurs.
C. Wear a mask when standing at the bedside of the client.
A client with suspected meningitis had a lumbar puncture. What is indicative of bacterial
Decreased glucose
Scenario: A nurse is assisting an RN admit a client who is diagnosed with bacterial meningitis from Neisseria meningitidis. Which of the following findings should the nurse expect? (Select all that apply.) ___ Fever ___ Photophobia ___ Vomiting ___ Hemiparesis ___ Bradycardia
Fever Photophobia Vomiting Hemiparesis
The nurse is providing post-procedure care for a patient who has had a lumbar puncture. Which order does the nurse anticipate?
Have patient lay flat for several hours.
A client is scheduled for a cerebral angiogram. Which would the nurse not need to check?
Liver function studies
what lab is monitored if a client is taking divalproex sodium for a seizure disorder?
Liver function studies
The nurse is admitting a client who takes selegiline hydrochloride. It treats which disorder?
Parkinson's disease
Scenario: An older adult client was diagnosed with Parkinson's disease (PD) 1 year ago. He is currently living independently with his wife of 50 years and takes levodopa with carbidopa (Sinemet) to control his disease. Due to a recent episode of aspiration pneumonia, the client has been admitted to the hospital for IV antibiotic and respiratory therapies. Which of the following findings should the nurse expect to find when collecting data? (Select all that apply.) ___ Decreased vision ___ Pill-rolling tremor of the fingers ___ Shuffling gait ___ High pitched, squeaky voice ___ Lack of facial expressions ___ Frequent periods of sleep
Pill-rolling tremor of the fingers Shuffling gait Lack of facial expressions
A patient with Parkinson's disease has difficulty tying shoes. What nursing intervention would be most helpful?
Providing Velcro fasteners allows the patient to remain independent as long as possible
Scenario: A nurse is assisting an RN admit a client who is diagnosed with bacterial meningitis from Neisseria meningitidis. What associated risk factors may the client report to the nurse when collecting data? (Select all that apply.) ___ Residential living in a dormitory ___ Current treatment of asthma with corticosteroids ___ Report of being bitten by a tick ___ History of otitis media ___ History of multiple mosquito bites while camping
Residential living in a dormitory Current treatment of asthma with corticosteroids History of otitis media
Which if stated by the nurse, is incorrect about a lumbar puncture?
Restrict fluid intake for a period of two hours
What would the nurse note during the clonic phase of a tonic clonic seizure?
Rhythmic jerking of the extremities
A client has a cerebellar lesion. What item would the nurse plan to obtain for this client?
Walker
Which statement by the nurse would be most reassuring to a client nervous about having an MRI?
You are alone but able to communicate with the tech
The nurse is assisting as a neurosurgeon examines a patient who has a positive Babinski reflex. What assessment finding should the nurse expect to observe? a. The leg flexes when the patellar tendon is struck. b. The leg extends when the patellar tendon is struck. c. The big toe extends when the sole of the foot is stroked. d. Toes curl downward when the sole of the foot is stroked.
c. The big toe extends when the sole of the foot is stroked.
The nurse is preparing the room for a client with seizures. Which item would not be included?
padded tongue blade
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 ANS:4
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." ANS:3
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 ANS:4
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 ANS:4
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 ANS:4
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." ANS:1
The client is taking phenytoin (Dilantin) for seizure control, and a blood sample for a serum drug level is drawn. which Lab finding indicates a therapeutic serum drug result?
1. 5 mcg/ml 2. 15 mcg/ml 3. 25 mcg/ml 4. 30 mcg/ml ANS: 2
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 ANS:3
A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? Select all that apply
A. Use the GCS to evaluate the client B. Assist the client to a supine position C. Admin an opioid med D. Encourage the client to increase fluid intake E. Remove the bandage on the client's puncture site ANS: B,C,D
A nurse is collecting data from a client who has a seizure disorder. The client reports sensing an aura and is about to have a seizure. Which of the following actions should the nurse implement? Select all that apply
A. provide privacy B. Ease the client to the floor if standing C. Move furniture D. Loosen the client's clothing E. Protecting the client's head with padding F. Restrain the client ANS: A,B,C,D,E
A nurse is reinforcing education about trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? Select all that apply
A. Avoid overwhelming fatigue B. Remove caffeinated products from the diet C. Limit looking at flashing lights D. Perform aerobic exercise E. Limit episodes of hypoventilation F. Use of aerosol hairspray is reccommended ANS: A,B,C
A nurse is reinforcing discharge instructions with a female client who has a prescription for phenytoin. Which of the following information should the nurse include?
A. Consider taking oral contraceptives when on this medication B. Watch for receding gums when taking the medication C. Take the medication at the same time every day D. Provide a urine sample to determine therapeutic levels of the medication ANS: C
The nurse is caring for a client who is taking phenytoin (Dilantin) for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information should the nurse provide to the client?
1. Pregnancy should be avoided while taking phenytoin (Dilantin) 2. The client may stop taking the phenytoin (Dilantin) if it is causing severe gastrointestinal effects. 3. The potential for decreased effectiveness of the birth control pills exists while taking phenytoin (Dilantin) 4. The increased risk of thrombophlebitis exists while taking phenytoin (Dilantin) and birth control pills together ANS: 3
A nurse is collecting data from a client who has Parkinson's disease. Which of the following findings should the nurse expect? Select all that apply
A. Decreased vision B. Pill-rolling tremor of the fingers C. Shuffling gait D. Drooling E. Bilateral ankle edema F. Lack of facial expression ANS: B,C,D
A nurse is using the GCS to check a client for changes in the level of consciousness. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document?
A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8 ANS: B
Which laboratory result would verify the diagnosis of bacterial meningitis?
1. Clear CSF with high protein and low glucose levels 2. Cloudy CSF with low protein and low glucose levels 3. Cloudy CSF with high protein and low glucose levels 4. Decreased pressure and cloudy CSF with a high protein level ANS:3
The nurse is collecting neurological data on an unconscious client. On application of a central noxious stimulus, the nurse observes this response (refer to figure). How should the nurse document this response on the client's record?
1. Client demonstrated ataxic posturing. 2. Client demonstrated decorticate posturing. 3. Client demonstrated decerebrate posturing. 4. Client demonstrated opisthotonic posturing. ANS:3
A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply.
1. Cola is acceptable to drink on the day of the test. 2. Tea and coffee are restricted on the day of the test. 3. The test will take between 45 minutes and 2 hours. 4. The hair should be washed the evening before the test. 5. All medications need to be withheld on the day of the test. 6. A nothing-by-mouth (NPO) status is required on the day of the test. ANS:2,3,4
A nurse is collecting data on a client with Parkinson's disease. Which finding indicates a serious complication of this disorder?
1. Congested cough and coarse rhonchi heard on auscultation 2. Last bowel movement was 48 hours ago 3. Resting and pill-rolling tremors 4. Shuffling and propulsive gait ANS:1
A clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. The nurse notes that the client is prescribed selegiline hydrochloride (Eldepryl). The nurse understands that this medication is prescribed for which diagnosis?
1. Coronary artery disease 2. Diabetes mellitus 3. Alzheimer's disease 4. Parkinson's disease ANS:4
A child has been diagnosed with meningococcal meningitis. Which precautionary technique is appropriate to prevent transmission of the disease?
1. Enteric precautions 2. Neutropenic precautions 3. No precautions are required as long as antibiotics have been started 4. Isolation precautions for at least 24 hrs after the initiation of antibiotics ANS:4
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. ANS:1
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 ANS:4
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On data collection of the child, the nurse expects to note which characteristics of this type of posturing?
1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities ANS: 3
The nurse is caring for a client with increased ICP. Which change in VS would occur if ICP is rising ?
1. Increasing temp, increasing pulse, increasing resp., decreasing BP 2. Decreasing temp, decreasing pulse, increasing resp, decreasing BP 3. Decreasing temp, increasing pulse, decreasing resp, increasing BP 4. Increasing temp, decreasing pulse, decreasing resp, increasing BP ANS:4
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 ANS:1
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. ANS:1
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 ANS:3
A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.
1. Monitor the client's ability to void. 2. Maintain the client in a flat position. 3. Restrict fluid intake for a period of 2 hours. 4. Monitor the client's ability to move the extremities. 5. Inspect the puncture site for swelling, redness, and drainage. 6. Maintain the client on a nothing-by-mouth (NPO) status for 24 hours. ANS:1,2,4,5
A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. (Refer to figure.) How should the nurse record this finding on the client's medical record?
1. Positive Kernig's sign 2. Positive Babinski's sign 3. Positive Trousseau's sign 4. Positive Brudzinski's sign ANS:1
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. ANS:1
A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply
1. Pad the bed's and side rails 2. Place an airway at the bedside 3. Place oxygen equipment at the bedside 4. Place suction equipment at the bedside 5. Tape a padded tongue blade to the wall at the HOB ANS: 1,2,3,4
A nurse is collecting admission data on a client with Parkinson's disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which of the following in the client's record?
1. Positive Romberg's test 2. Negative Romberg's test 3. Positive Trousseau's sign 4. Negative Trousseau's sign ANS:1
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 ANS:2
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 ANS:2
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 ANS:3
A patient with a history of seizures reports experiencing an aura and is concerned about an impending seizures. Place the nurse's interventions in the correct order.
1. Protect the patient from injury during the seizure 2. Document the events of the seizure 3. Help the patient lie down in a safe place 4. Turn the patient on his or her side to sleep ANS: 3,1,4,2
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 ANS:1
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 ANS:1
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 ANS:1,2,3
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 ANS:1,2,3,6
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) ANS:1,2,3,5
The client is having a lumbar puncture performed. The nurse should place the client in which position for the procedure?
1. Supine, in semi fowlers 2. Prone, in slight Trendelenburg's 3. Prone, with a pillow under the abdomen 4. Side lying, with legs pulled up and chin to the chest ANS: 4
A nurse is caring for a client that is comatose and notes in the client's chart that the client is exhibiting decerebrate posturing. The nurse understands that decerebrate posturing is characterized by:
1. The extension of the extremities and pronation of the arms 2. The 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 ANS:1
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. ANS:3
The nirse is assisting to develop a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply
1. Time the seizure 2. Restrain the child 3. Stay with the child 4. Place the child in a prone position 5. Move furniture away from the child 6. Insert a padded tongue blade into thr child's mouth ANS: 1,3,5
A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem?
1. Use a wheelchair to move around. 2. Stand erect and use a cane to ambulate. 3. Keep the feet close together while ambulating and using a walker. 4. Consciously think about walking over imaginary lines on the floor. ANS:4
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 ANS:3
A nurse is caring for a client who has AD. A family member of the client ask the nurse about risk factors for the disease. Which of the following information should the nurse include? Select all that apply
A. Exposure to metal waste products B. Long-term estrogen therapy C. Sustained use of vitamin E D. Previous head injury E. History of herpes infection ANS: A,D,E
A nurse is reinforcing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include?
A. "I will have a sore throat after placement of the stimulator" B. "This stimulator will stop my tonic/clonic seizures" C. "I can expect to have a temporary voice change" D. "The device is inserted under local anesthesia" ANS: C
A nurse working in a long term care facility is caring for a client who has AD. Which of the following actions should the nurse take?
A. Allow the client to sleep whenever he chooses B. Avoid using gestures when communicating with the client C. Redirect the client when he talks about the past D. Provide finger foods for the client's snacks and meals ANS: D
A nurse is reinforcing teaching with a client who is scheduled for a CT scan with contrast. Which of the following statements by the the client indicates understanding of the teaching?
A. "I should not have caffeine 48 hr before the procedure" B. " I will have my kidney function checked before the test" C. "I should tape my wedding band in place before the procedure" D. "I will have my brain activity monitored during the test" ANS:B
A nurse is reviewing the plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? Select all that apply
A. "I think I might be pregnant" B. "I take warfarin" C. "I take antihypertensive medication" D. "I am allergic to shrimp" E. "I ate a light breakfast this morning" ANS: A,B,D,E
A nurse is contributing to the plan of care for a client who has meningitis and is at risk for ICP. Which of the following interventions should the nurse recommend? Select all that apply
A. Implement seizure precautions B. Perform neurological checks four times a day C. Administer morphine for the report of neck and generalized pain. D. Turn off room lights and television. E. Monitor for impaired extraocular movements F. Encourage the client to cough frequently ANS: A,D,E
A nurse is reviewing the plan of care for a client who has PD. Which of the following interventions should the nurse identify as the priority?
A. Recommend a community support group B. Integrate a daily exercise routine C. Provide a walker for ambulation D. Schedule a swallowing evaluation ANS: D
A nurse is caring for a client who has PD and is starting to display bradykinesia. Which of the actions should the nurse take?
A. Remind client to walk more quickly when ambulating B. Complete passive range-of-motion exercise daily C. Place the client on a low protein, low calorie diet D. Give the client extra time to perform activities ANS: D
A nurse is reinforcing teaching with the partner of an older adult client who has AD and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective?
A. This medication should increase my partner's appetite B. This medication should help my partner sleep better C. This medication should help my partner's daily function D. This medication should increase my partner's energy level ANS: C
The nurse observes the unlicensed assisstive personnel (UAP) positioning the client with ICP. Which position would require intervention by the nurse?
1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. HOB elevated 30 to 45 degrees ANS: 2
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. ANS:3
Phentoin (Dilantin), 100 mg orally TID has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicated an understanding of the instructions?
1. "I will use a soft toothbrush to brush my teeth" 2. "It's alright to break the capsules to make it easier for me to swallow them" 3. "If I forget to take my medication, I can wait until the next dose and eliminate that dose" 4. "If my throat becomes sore, it's a normal effect of the medication and it's mothing to be concerned about" ANS: 1
A nurse is checking for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take? Select all that apply
A. Place client in supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest E. Straighten the client's flexed leg at the knee ANS: A,C,D
A nurse is contributing to a plan of care for the nutritional needs of a client who has stage IV PD. Which of the following actions should the nurse include in the plan of care? Select all that apply
A. Provide three large balanced meals daily B. Record diet and fluid intake daily C. Document weight every other week D. Place the client in Fowler's position to eat E. Offer nutritional supplements between meals ANS: B
A nurse is making a home visit to a client who had AD. The client's partner states that the client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the following safety measures should the nurse review with the partner ? Select all that apply
A. Remove floor rugs B. Have door locks that can be easily opened C. Provide increased lighting in stairwells D. Install handrails in the bathroom E. Place the mattress on the floor ANS: A,C,D,E
A nurse is contributing to the plan of care for a client who has bacterial meningitis. Which of the following interventions should the nurse include? Select all that apply
A. Monitor for hypotension B. Provide an emesis basin at the bedside C.Administer antipyretic medication D. Perform a skin assessment E. Keep HOB flat ANS:B,C,D
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 ANS:2
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. ANS:4
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 ANS:2
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 ANS:2
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 ANS:1
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. ANS:1
A nurse is caring for a client who has AD and falls frequently. Which of the following actions is the priority for the nurse to take to keep the client safe?
A. Keep the call light near the client B. Place the client in a room close to the nurses' station C. Encourage the client to ask for assistance D. Remind the client to walk with someone for support ANS: B
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?
A. Keep the client in a side- lying position. B. Document the duration of the seizure C. Reorient the client to the environment D. Provide client hygiene ANS: A
