Neurosensory Disorders

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A) Sit with the client for a few minutes. B) Administer an analgesic. C) Inform the nurse manager. D) Call the physician immediately.

D) Call the physician immediately. Reason: The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? A) Trendelenburg's B) 30-degree head elevation C) Flat D) Side-lying

B) 30-degree head elevation Reason: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? A) Decreased level of consciousness (LOC) B) Elevated blood pressure C) Increased urine output D) Decreased heart rate

C) Increased urine output Reason: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following? A) Contact the client's audiologist. B) Cleanse the hearing aid ear mold in normal saline. C) Irrigate the ear canal. D) Check the hearing aid's placement.

D) Check the hearing aid's placement. Reason: Inadequate amplification can occur when a hearing aid is not placed properly. The certified audiologist is licensed to dispense hearing aids. The ear mold is the only part of the hearing aid that may be washed frequently; it should be washed daily with soap and water. Irrigation of the ear canal is done to remove impacted cerumen or a foreign body.

Which of the following is an early symptom of glaucoma? A) Hazy vision. B) Loss of central vision. C) Blurred or "sooty" vision. D) Impaired peripheral vision.

D) Impaired peripheral vision. Reason: In glaucoma, peripheral vision is impaired long before central vision is impaired. Hazy, blurred, or distorted vision is consistent with a diagnosis of cataracts. Loss of central vision is consistent with senile macular degeneration but it occurs late in glaucoma. Blurred or "sooty" vision is consistent with a diagnosis of detached retina.

A potential concern when caring for an older adult who has diminished hearing and vision is the client's: A) Feelings of disorientation. B) Cognitive impairment. C) Sensory overload. D) Social isolation.

D) Social isolation. Reason: Social isolation is a concern for an older adult who has diminished hearing and vision. Feeling disoriented may be related to cognitive problems rather than diminished hearing and vision. Diminished hearing and vision is related to the aging process and does not result in impairment of the older adult's thought processes. The client with impaired hearing and vision is unlikely to experience sensory overload.

Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? A) Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks. B) Activity level is determined by the client's tolerance; she can be as active as she wishes. C) Activity level will be restricted for several months, so she should plan on being sedentary. D) Activity level can return to normal and may include regular aerobic exercises.

A) Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks. Reason: The scarring of the retinal tear needs time to heal completely. Therefore, resumption of activity should be gradual; the client may resume her usual activities in 5 to 6 weeks. Successful healing should allow the client to return to her previous level of functioning.

A nurse is monitoring a client for adverse reactions to atropine (Atropine Care) eye drops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A) Tachycardia B) Increased salivation C) Hypotension D) Apnea

A) Tachycardia Reason: Systemic absorption of atropine can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. The drug also may cause dry mouth. It isn't known to cause hypotension or apnea.

A nurse on a rehabilitation unit is caring for a client who sustained a head injury in a motor vehicle accident. She notes that the client has become restless and agitated during therapy; previous documentation described the client as cooperative during therapy sessions. The nurse's priority action should be to: A) gather assessment data and notify the physician of the change in the client's status. B) ask the physician to order an antipsychotic medication for the client. C) consult with the social worker about the possibility of discharging the client from the facility. D) tell the client that she'll punish him if he doesn't behave.

A) gather assessment data and notify the physician of the change in the client's status. Reason: A client with a head injury who experiences a change in cognition requires further assessment and evaluation, and the nurse should notify the physician of the change in the client's status. The physician should rule out all possible medical causes of the change in mental status before ordering antipsychotic medications or considering discharging the client from the facility. A nurse shouldn't threaten a client with punishment; doing so is a violation of the client's rights.

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed? A) Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the physician. B) Ask the nursing assistant to notify the physician of the low pulse oximetry level. C) Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. D) Complete the assessment of the new client before attending to the client who underwent laminectomy.

C) Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Reason: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? A) Shock B) Encephalitis C) Increased intracranial pressure (ICP) D) Status epilepticus

C) Increased intracranial pressure (ICP) Reason: When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: A) provide instructions on eye patching. B) assess the client's visual acuity. C) demonstrate eye drop instillation. D) teach about intraocular lens cleaning.

C) demonstrate eye drop instillation. Reason: Eye drop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eye drop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.