NU310: Neurologic Alterations

The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions? a. "I have a leftover prescription at home I can use if I have pain" b. "I will cancel the wine tasting I have planned for this weekend" c. "I will have someone drive me home and will take a couple of days off work" d. "I will have someone stay with me and sure I am okay"

a. "I have a leftover prescription at home I can use if I have pain"

The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching? a. "I have to remember to raise my chin slightly upward when I swallow" b. "I have to remember to swallow 2 times before taking another bite of food" c. "I should avoid taking over-the-counter cold medications when I'm sick" d. "I should sit upright for at least 30-40 minutes after I eat"

a. "I have to remember to raise my chin slightly upward when I swallow"

The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding? a. A tongue blade is used to touch the client's pharynx; gag reflux is absent b. Only one side of the mouth moves when the client is asked to smile and frown c. The absence of light tough and pain sensation on the left side of the client's face d. When the client shrugs against resistance, the left shoulder is weaker than the right

a. A tongue blade is used to touch the client's pharynx; gag reflux is absent

A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? Select all that apply. a. Administer PRN stool softeners daily b. Administer scheduled enoxaparin injection c. Implement seizure precautions d. Keep client NPO until swallow screen is performed e. Perform frequent neurological assessments

a. Administer PRN stool softeners daily c. Implement seizure precautions d. Keep client NPO until swallow screen is performed e. Perform frequent neurological assessments

Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit? a. Aphasia b. Apraxia c. Dysarthria d. Dysphagia

a. Aphasia

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock? a. Apical heart rate 48/min b. Blood pressure 186/92 mm Hg c. Cool, clammy skin d. Temperature 100 F (37.7 C) tympanic

a. Apical heart rate 48/min

A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take? a. Arouse the client and ask what the current month is b. Document "relief apparently obtained" and recheck at 03:00 AM c. Let the client sleep but verify respiratory rate d. Wake the client up and check for paresthesia

a. Arouse the client and ask what the current month is

The nurse is caring for a client who had a stroke 2 weeks ago and has moderate receptive aphasia. The nurse is trying to get the client to follow simple commands regarding activities of daily living (ADL). Which nursing interventions should be included in the plan of care? Select all that apply. a. Ask simple questions that require "yes" or "no" answers b. If the client becomes frustrated, seek a different care provider to complete ADL c. Perform ADL for the client until the goal of each activity is understood d. Show the client gestures or pictures of ADL (shower, toilet, and toothbrush) e. Speak slowly but loudly while looking directly at the client

a. Ask simple questions that require "yes" or "no" answers d. Show the client gestures or pictures of ADL (shower, toilet, and toothbrush)

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? a. Auscultate breath sounds to assess for crackles b. Monitor for >50 mL/hr urine output c. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 d. Press over the tibia to assess for pitting edema

a. Auscultate breath sounds to assess for crackles

The nurse is assessing a newly admitted client on a neurological inpatient unit. Which assessment findings are abnormal and require follow-up by the nurse? Select all that apply. a. Cannot touch chin to chest b. Eyes roll in opposite direction when turning head side to side c. Muscle strength of lower extremities is 3/5 d. Pupils are 8 mm in diameter e. Toes point downward when noxious stimuli are applied to the sole

a. Cannot touch chin to chest c. Muscle strength of lower extremities is 3/5 d. Pupils are 8 mm in diameter

A client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? Select all that apply. a. Client should abstain from alcohol b. Client should remain awake all night c. Client should return if having difficulty d. Responsible adult should be taught neurological examination e. Responsible adult should stay with the client

a. Client should abstain from alcohol c. Client should return if having difficulty e. Responsible adult should stay with the client

The nurse receives the change of shift report for assigned clients at 7 AM. Which client should the nurse assess first? a. Client with change in level of consciousness who fell in the nursing home b. Client with chronic headaches who is scheduled for an MRI at 9 AM c. Client with chronic obstructive pulmonary disease (COPD) and pulse oximeter reading of 90% d. Client with heart failure and 3+ pitting edema of the lower extremities

a. Client with change in level of consciousness who fell in the nursing home

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply. a. Asymmetrical pupillary constriction b. Brief loss of consciousness c. Headache d. Loss of vision e. Retrograde amnesia

b. Brief loss of consciousness c. Headache e. Retrograde amnesia

A client is brought to the emergency department with stroke symptoms that began 7 hours ago. A CT scan confirms the presence of an ischemic stroke. The client's current blood pressure is 202/108 mm Hg. Which nursing action is most appropriate? a. Anticipate IV labetalol to keep blood pressure <140/90 mm Hg b. Document the current findings in the client's chart c. Prepare to administer thrombolytic therapy d. Request a prescription for IV antiseizure medication

b. Document the current findings in the client's chart

The nurse is caring for a client with a history of headaches. The client has talked to the nurse, smiled at guests, and maintained stable vital signs. The nurse notes the following changes in the client's status. Which assessment finding is critical to report to the health care provider (HCP)? a. Blood pressure 136/88 mm Hg b. Flat affect and drowsiness c. Poor appetite d. Respiratory rate 12/min

b. Flat affect and drowsiness

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include? a. Belief that the current surrounding are a racetrack b. GCS score was "11" one hour ago c. Recent vital signs show blood pressure of 120/80 mm d. Hg and pulse of 82/min e. Reported allergy to penicillin and vancomycin

b. GCS score was "11" one hour ago

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV antibiotics b. Infuse bolus of IV normal saline c. Prepare to assist with lumbar puncture d. Transport client for head CT scan

b. Infuse bolus of IV normal saline

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate? a. Give the antihypertensive medication b. Monitor the blood pressure c. Notify the health care provider d. Question the prescription

b. Monitor the blood pressure

A client is receiving several adjunctive professional therapies while rehabilitating after a stroke. Which client statements indicate an understanding of the services? Select all that apply. a. "Occupational therapy will help me learn how to properly use my walker." b. "Physical therapy will help me learn how to dress myself again." c. "Social services can help me find resources for affording my medications." d. "Speech therapy will teach me how to eat my meals properly." e. "Wound care will teach me how to properly dress this wound on my knee."

c. "Social services can help me find resources for affording my medications." d. "Speech therapy will teach me how to eat my meals properly." e. "Wound care will teach me how to properly dress this wound on my knee."

The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first? a. Client with history if head injury whose Glasgow Coma Scale (GCS) changes from 13 to 14 b. Client with history of myasthenia gravis who has ptosis in the evening c. Client with history of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension d. Client with history of transverse myelitis with 2+ bilateral lower extremity muscle strength

c. Client with history of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? a. Administer atropine for bradycardia b. Administer nifedipine for hypertension c. Have CT scan performed to rule out an intracranial bleed d. Perform hourly neurologic checks with Glasgow coma scale (GCS)

c. Have CT scan performed to rule out an intracranial bleed

A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action? a. Determine onset of symptoms b. Ensure that the client has 2 large-bore intravenous (IV) lines c. Maintain patent airway d. Prepare for head CT scan

c. Maintain patent airway

A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? a. Document the amount of emesis b. Lower the head of the bed c. Notify the health care provider (HCP) d. Offer anti-nausea medication

c. Notify the health care provider (HCP)

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? a. "I am very tired, and it's hard to for me to keep my eyes open" b. "I don't feel good, and I want to be seen" c. "I have not taken my blood pressure medicine in over a week" d. "I have the worst headache I've ever had in my life"

d. "I have the worst headache I've ever had in my life"

The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse? a. "I will raise the head of the bed so it is easier to see the television" b. "I will turn down the lights when I leave" c. "Let me move your belongings closer so you can reach them" d. "You should do deep breathing and coughing exercises"

d. "You should do deep breathing and coughing exercises"

A client with stroke symptoms has a blood pressure of 240/124 mm Hg. The nurse prepares the prescribed nicardipine intravenous (IV) infusion solution correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse's priority action at this time? a. Assess hourly urinary output b. Increase pump setting to correct administration rate to 100 mL/hr d. Keep systolic blood pressure above 170 mm Hg e. Monitor for a widening QT interval

d. Keep systolic blood pressure above 170 mm Hg

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client? a. Risk for ineffective airway maintenance b. Risk for knowledge deficit c. Risk for poor fluid intake d. Risk for self-neglect

d. Risk for self-neglect

The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? a. History of bell's palsy wit unilateral facial droop and drooling b. History of multiple sclerosis and reporting recent blurred vision c. Reports unilateral facial pain when consuming hot foods d. Temple region hit by ball, loss of consciousness, but Glasgow score is now 14

d. Temple region hit by ball, loss of consciousness, but Glasgow score is now 14

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do? a. Bend at the wrist b. Keep the feet close together c. Pivot on the foot proximal to the chair d. Use a transfer belt

d. Use a transfer belt