Neurosensory Disorders
Which statement indicates that a client understands the nurse's teaching about phenytoin for the diagnosis of seizures?
"This medication will not cure my disease."
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays have not been read, so the nurse does not know whether the client has a cervical spinal injury. The nurse develops a plan of care and includes which action?
Maintain the client in a flat position, except for logrolling as needed.
The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the healthcare provider?
worsening headache
As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability?
"I can participate in sexual activity but might not experience orgasm."
A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction?
"I don't really need to sign anything. I'm depending on my physician to tell my family what to do if something bad happens."
A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin. Client teaching about this drug should include which instruction?
"Schedule follow-up visits with your physician for blood tests."
The nurse observes that the client with multiple sclerosis looks untidy and sad. The client suddenly says, "I can't even find the strength to comb my hair," and bursts into tears. Which response by the nurse is best?
"Tell me more about how you're feeling."
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate?
"The most common cause of dementia in the elderly is Alzheimer's disease."
A nurse is preparing to administer phenytoin to a 99-lb (45-kg) client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be administered in the first dose? Record your answer as a whole number.
75
A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?
Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.
Which technique is appropriate when the nurse is irrigating an adult client's ear to move cerumen?
Allow the irrigating solution to run down the wall of the ear canal.
What is the priority nursing intervention in the postictal phase of a seizure?
Assess the client's breathing pattern.
A client has an impairment of cranial nerve II. Which safety precautions must the nurse implement? Select all that apply.
Clear any obstacles in a path for walking. Instruct on the use of a wheeled walker.
Because of symptoms experienced after a cerebrovascular accident (CVA), the nurse discovers that a client needs assistance using utensils while eating. What would the nurse do to support this activity of care?
Encourage participation in the feeding process to the best of the client's abilities.
A client has an increased intracranial pressure (ICP) of 20 mm Hg. What should the nurse do next?
Encourage the client to take deep breaths to hyperventilate.
A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the client's first response to pain will be to do what?
Escape the source of pain.
The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?
Increase the frequency of client observation
A client with a new diagnosis of myasthenia gravis asks, "What is happening to me?" What would be the most appropriate response by the nurse?
It is a chronic disease in which there is a disturbance in nerve transmission to the muscle, resulting in fatigue and muscle weakness.
The nurse has administered mannitol IV. Which is a priority assessment for the nurse to make after administering this drug?
Monitor urine output.
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
The nurse is completing a neurologic assessment on a client admitted with a contusion to the brain. Which finding does the nurse prioritize as requiring immediate action?
Pupils are equal with sluggish reaction to light.
Sodium polystyrene sulfonate is prescribed for a client following crush injury. Which finding indicates the drug has been effective?
The serum potassium is 4.0 mEq/L (4.0 mmol/L).
The nurse should inform a client with Ménière's disease that before an attack of the disease, the client may experience:
a feeling of inner ear fullness.
A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately?
new onset of footdrop
The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which?
positions the client on the back with a small pillow under the head
A client is admitted to the hospital with an exacerbation of multiple sclerosis after an MRI revealed progressive demyelination. The nurse should assess for which symptom? Select all that apply.
progressive weakness of the extremities inability to ambulate independently urinary incontinence
It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. What should the nurse tell the client to do to prepare for this test?
"You will need to hold your head very still during the examination."
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
Alternatively patch one eye every 2 hours.
The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. What should the nurse do next?
Readminister the residual to the client, and continue with the feeding.
What assessment findings would the nurse expect in a client with progressive myasthenia gravis?
muscle weakness, difficulty swallowing, double vision, and difficulty speaking
A client is having a tonic-clonic seizure. What should the nurse do first?
Take measures to prevent injury.
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?
Test the nasal drainage for glucose.
The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which topic is most important to include in the plan?
maintaining a safe environment
The nurse is assessing a client who has had Huntington's disease for the past 8 years. Which clinical manifestation finding would require the nurse to notify the client's primary healthcare provider?
akathisia Motor restlessness is a sign of overmedication, and therefore should be reported to the client's primary healthcare provider. The other clinical manifestations are expected in a client with Huntington's disease.
When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for which health problem?
aspiration
For a neurologically injured client, the nurse should assess motor strength by:
comparing equality of hand grasps.
The nurse should assess the client with multiple sclerosis for which associated health problem?
mood disorders
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?
decrease in level of consciousness (LOC)
An auto mechanic accidentally has battery acid splashed in their eyes. The coworkers irrigate the eyes with water for 20 minutes, then take the mechanic to the emergency department of a nearby hospital, where the mechanic receives emergency care for corneal injury. The physician orders dexamethasone, two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate, 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. The nurse knows that dexamethasone exerts its therapeutic effect by
decreasing leukocyte infiltration at the site of ocular inflammation.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include
diminished responsiveness.
Which nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?
disorientation, increasing blood pressure, bradycardia, and bradypnea
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates
dysfunction in the brain stem.
Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order
famotidine.
The client with a lumbar laminectomy asks to be turned onto the side. The nurse should:
get another nurse to help logroll the client into position.
A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
hemiplegia, seizures, and decreased level of consciousness (LOC)
A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which nursing diagnosis is the priority?
impaired swallowing
The nurse is administering eye drops to a client with glaucoma. Which technique is correct for instilling the eye drops? The eye drops are placed:
in the lower conjunctival sac.
The nurse is assessing a client with a head injury. On admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in neurologic status suggest to the nurse?
increased intracranial pressure
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?
increased intracranial pressure (ICP)
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?
increased restlessness
The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease?
low sodium
A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?
suction machine with catheters
Which is not a typical clinical manifestation of multiple sclerosis (MS)?
sudden bursts of energy
A nurse is monitoring a client for adverse reactions to atropine eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?
tachycardia
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean them from sedation therapy. A nurse needs further assessment data to determine whether
the nurse will have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.
Which goal is collaboratively established by the client with Parkinson's disease, the nurse, and the physical therapist?
to maintain joint flexibility
The client asks when to stop taking the eye medication for chronic open-angle glaucoma. The nurse should tell the client:
to use the eye medication for the rest of life.
A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?
unequal pupil size