Ortho Test 1

What will the nurse recommend to the client starting therapy with meclizine (Antivert)?

"Avoid caffeinated coffee or soft drinks while taking this medication." Antivert can cause dry mouth, which can be made worse by the consumption of caffeinated beverages

Which precautions or instruction should the nurse teach the client who is going to have electroretinography of the eye?

"Avoid rubbing your eyes until the anesthetic drops have worn off." The client could inadvertently scratch or harm the eye by touching or rubbing it while the anesthetic effect is present.

Which recommendation will the nurse provide for the client with Ménière's disease who has periodic spells of vertigo?

"Avoid wearing high-heeled shoes." Clients with vertigo should wear low-heeled shoes with non-skid soles and tied laces to prevent injury

Which instruction will the nurse provide about a cephalexin (Keflex) prescription that the client will be taking at home after tympanoplasty surgery?

"Be sure to finish all the Keflex pills, even if you feel fine." Keflex is an antibiotic. Clients should be sure to take the entire course of therapy to prevent the development of infection with resistant microorganisms

Which is the most important information for the nurse to teach a client who is receiving cycloplegic drug therapy?

"Do not drive or operate machinery until the drug wears off." Cycloplegic agents prevent accommodation of the iris, resulting in a widely dilated pupil

The client is prescribed phenytoin (Dilantin) for treatment of a seizure disorder. What precautions or instructions should be taught to this client?

"Do not take warfarin (Coumadin) while on this medication." Warfarin inhibits the metabolism of phenytoin, increasing the half-life of phenytoin and the risk of toxic levels.

When interviewing an acutely confused patient with a head injury, which of these questions will provide the most useful information?

"Do you have any pain at the present time?" The acutely confused patient will be able to state whether there is pain currently

Atonic Seizure

"Drop Attack " The primary drugs to treat generalized tonic-clonic and partial seizures are phenytoin (Dilantin), carbamazepine (Tegretol), phenobarbital, and divalproex (Depakote). (Lewis 1496)

When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I always sleep with the radio on." Which response by the nurse is most appropriate?

"Have you noticed any ringing in your ears?" Patients with tinnitus may use masking techniques, such as playing a radio, to block out the ringing in the ears

The health care provider prescribes phenytoin (Dilantin) for control of complex partial seizures. After the nurse has taught the patient about phenytoin, which patient statement indicates understanding of the medication?

"I may need to have my blood taken frequently to check the level of the Dilantin." Serum levels of phenytoin may be checked to ascertain that a therapeutic level of the medication is achieved

The nurse is obtaining a health history for a 64-year-old patient with glaucoma who is a new patient at the eye clinic. Which information given by the patient will have the most implications for the patient's treatment?

"I take metoprolol (Lopressor) daily for angina." It is important to note whether the patient takes any beta-adrenergic blockers because this category of medications is also used to treat glaucoma and there may be an increase in adverse effects.

The client with long-standing primary open-angle glaucoma and loss of 60% of her visual fields is about to undergo surgical treatment to create a new drainage channel for the aqueous humor. Which of the following statements made by the client indicates a lack of understanding regarding this treatment?

"I will probably not regain my total vision again for at least 2 weeks." Surgery for glaucoma does not correct vision that is lost; it relieves pressure to prevent further loss

Which statement indicates that the client needs additional teaching about protecting the ears and preventing hearing loss?

"I will take Motrin (ibuprofen) instead of Tylenol (acetaminophen), as needed, for my arthritis pain." Motrin (ibuprofen) can be ototoxic. Its use should be avoided to help prevent additional hearing loss

A patient with age-related macular degeneration has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective?

"I will wear a hat, long-sleeved shirt, and pants for the next 5 days." The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment.

The client requires a hearing aid but tells the nurse that he cannot afford to pay for it right now. What is the nurse's best response?

"I'll ask the social worker to check if any local organizations help people pay for hearing aid."

A graduate nurse is orienting to the neurologic ICU. The new nurse asks their preceptor what is meant by "lacunar" stroke. What would be the preceptor's best reply?

"Lacunar strokes are small-artery thrombotic strokes."

The nurse talking with a client with open-angle glaucoma would instruct the client to make a behavior change based on the statement

"Now that the allergy season is here, I take antihistamines on a regular basis." Many over-the-counter (OTC) medications, including antihistamines, can dilate the pupil, putting the client at risk for angle-closure glaucoma.

A patient with otosclerosis has a stapedectomy for treatment of hearing loss. Two days after the surgery, the patient tells the nurse, "I do not hear as well now as I did right after the surgery." Which response by the nurse is most appropriate?

"Postoperative accumulation of fluid and blood in your middle ear will temporarily decrease your hearing." Patients frequently have improved hearing immediately after surgery, which decreases postoperatively because of the accumulation of blood and drainage in the ear. The hearing will improve again as healing occurs.

The client has been treated with radiation therapy to the eye. What will the nurse teach the client?

"See your ophthalmologist for a complete eye examination yearly."

Which lifestyle modification should the nurse suggest to the client with Ménière's disease to reduce the frequency or intensity of acute episodes?

"Stop or reduce cigarette smoking." The vasoconstrictive effects of cigarette smoking reduce endolymph absorption and promote acute episodes of Ménière's disease.

Timolol (Timoptic) ophthalmic drops are prescribed for a patient with open-angle glaucoma. After using the drops for several days, the patient tells the nurse that the eyedrops cause eye burning and visual blurriness for a time. The best response by the nurse to the patient's complaint is,

"The drops are uncomfortable, but it is very important for you to use them as prescribed to retain your vision." : Patients should be instructed that eye discomfort and visual blurring are expected side effects of the ophthalmic drops but that the drops must be used to prevent further visual-field loss.

When obtaining a health history from a 52-year-old patient, which patient statement will be of most concern to the nurse?

"The middle part of my vision is decreased." The decrease in vision in the center of the visual field may indicate macular degeneration, which is not a normal visual change associated with aging

Family members are optimistic about a comatose patient's recovery because the patient's eyes open and the patient appears to be awake at times. Which statement by the nurse to the family is appropriate?

"The part of the brain responsible for arousal is not injured, but the wakefulness does not indicate improvement in higher brain centers." The behaviors of eye opening and wakefulness are not indicators of improvement in the comatose condition.

Which teaching is essential for the client who is going for intraocular pressure measurement?

"The test is quick and a local anesthetic is used." The different ways to measure intraocular pressure are performed with the eye anesthetized so that there is no pain

The nurse is caring for a client with Ménière's disease. What will the nurse recommend to the client to reduce the symptoms of vertigo?

"When dizziness begins, lie down and keep your head still."

A patient in the neurologic intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating would this patient have for verbal response?

1 The Glasgow Coma Scale assesses both level of consciousness and motor response to a stimulus. The scale has three sections: eye opening, motor response, and verbal response. If the patient is unable to talk because of intubation, the score is a 1

Normal IOP

10-21 mm Hg

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as

11 The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Legal Blindness Value

20/200

A patient has been declared legally blind. This means that the patient has a best corrected visual acuity (BCVA) that does not exceed what in the better eye?

20/200 Blindness is defined as a best corrected visual acuity (BCVA) that can range from 20/400 to no light perception (NLP). The clinical definition of absolute blindness is the absence of light perception. Legal blindness is a condition of impaired vision in which a person has a BCVA that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less

A 2-year-old girl is scheduled to have a myringotomy. How long would the nurse tell the parents that it will take for the incision to heal?

24 to 72 hours

The nursing instructor is teaching the Level 1 nursing students the proper way to instill eye drops in a patient's eye. How long would the instructor teach the students to wait between successive eye drops in the same eye to achieve adequate eye drop drug retention and absorption?

5 minutes A 5-minute interval between successive eye drop administration allows for adequate drug retention and absorption. Any timeframe less than 5 minutes will not allow adequate absorption.

The nurse explains that irreversible brain tissue damage is probable when the blood flow to the brain is reduced by

60%. When blood flow to the brain is reduced by 40%, cerebral tissue becomes acidotic. When the blood flow to the brain is reduced by 60% the electroencephalogram (EEG) pattern changes and the client is at risk for significant brain tissue damage. Cerebral metabolism is altered, which eventually leads to brain tissue hypoxia and areas of brain tissue ischemia.

CPP Normal Value

60-100

For which client does the nurse suspect secondary open-angle glaucoma?

78-year-old client who has a decreased sense of peripheral vision on the fourth postoperative day after cataract surgery with lens replacement Eye surgery is a common cause of secondary open-angle glaucoma.

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?

90 mm Hg CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg.

When planning care for a patient with increased intracranial pressure the nurse realizes that the cerebral perfusion pressure must be maintained at

> 70 mm Hg.

The nurse assesses several clients. Which one is most likely to have secondary open-angle glaucoma?

A client who has recently had eye surgery Secondary open-angle glaucoma results from another condition that interferes with the drainage of aqueous humor.

Which client would be excluded as a potential donor for corneal transplantation?

A client with hepatitis B Clients of any age may donate corneas as long as the corneas are clear and the client is free from infectious disease or cancer at the time of death.

Which client is a poor candidate for photorefractive radial keratectomy?

A client with severe astigmatism Severe astigmatism is a current contraindication for photorefractive radial keratectomy because the cornea is very uneven.

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse indicates an appropriate response to therapy?

A decrease in ICP and an increase in urine output Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output

During their pathophysiology class the nursing students study seizures. How might the instructor best describe the cause of a seizure?

A dysrhythmia in the nerve cells in one section of the brain The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain

During an assessment, a patient asks the nurse if "something is burning." The nurse realizes that this patient could be demonstrating:

A focal seizure Focal symptoms can occur in patients with brain tumors. The nurse should question the patient about any experienced symptoms such as muscle twitching or jerking of an arm or leg, abnormal smells or tastes, problems with speech, or numbness and tingling

Rhinorrhea Fluid Collection

A loose collection pad may be placed under the nose or over the ear. Do not place a dressing in the nasal or ear cavities. Instruct the patient not to sneeze or blow the nose. (Lewis 1444)

A patient is brought by ambulance to the emergency department after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?

A patient who is anticoagulated

When a client suffers a tonic-clonic seizure, the nurse should

A person having a seizure needs protection from the environment. The nurse should move objects out of the way, place some type of padding under the client's head, loosen clothing that is tight around the client's neck, turn the client to one side to facilitate draining saliva, and observe the characteristics of the seizure. Nothing should be forced into the client's mouth.

A patient with acute meningitis is receiving antibiotic therapy. The nurse realizes that another medication is used as adjuvant therapy. This medication is:

A steroid Steroids are currently recommended as adjunctive treatment of bacterial meningitis

A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, along with a change in vital signs, and became diaphoretic and agitated. The nurse would know that the patient is having what?

A sympathetic storm

A patient with a suspected head injury following an assault is being transported to the emergency department. What would the nurse expect the physician to order to aid in preventing secondary injury?

ABG An ABG would give baseline blood values to have a foundation in the maintenance of optimal blood gas values.

The nurse working with an ICP monitor institutes which actions? The nurse (Select all that apply) a. administers prophylactic antibiotics as ordered. b. limits the number of times the system is opened. c. manipulates the catheter frequently to ensure patency. d. uses strict aseptic technique to change dressings.

ANS: A, B, D Intracranial monitors all carry a high risk of infection, and because of their placement an infection has serious consequences. Interventions to minimize the risk of infection include options a, b, and d. The monitoring system is manipulated as little as possible and left in for the shortest amount of time possible.

The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care (choose all that apply)? a. Compare frequent neurological assessments with baseline. b. Maintain CO2 level at 50 mm Hg. c. Maintain mean arterial pressure less than 130 mm Hg and systolic blood pressure less than 220 mm Hg. d. Prepare for therapeutic thrombolytic administration. e. Restrain affected limb to prevent injury.

ANS: A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg. In hemorrhagic stroke the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy.

In assessing a client with injury to the temporal lobe, the nurse correlates which clinical manifestation with this damage? (Select all that apply.) a. Memory loss b. Personality changes c. Loss of temperature regulation d. Difficulty with sound interpretation e. Speech difficulties f. Impaired taste

ANS: A, D, E Wernicke's area (language area) is located in the temporal lobe and enables processing of words into coherent thought and understanding of written or spoken words. The temporal lobe also is responsible for the auditory center's interpretation of sound and complicated memory patterns. Personality changes are related to damage to frontal lobe injury. Loss of temperature regulation is seen with damage to the hypothalamus, and impaired taste is associated with injury to the parietal lobe.

Which precautions will the nurse institute to ensure the safety of a client with epilepsy who has been hospitalized? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue at bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

ANS: A, D, F The bed rails should be up at all times while the client is in the bed to prevent an injury from a fall if the client has a seizure. Padded tongue blades may pose a danger to the client during a seizure. Be sure that oxygen and suctioning equipment with an airway are readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure.

A nurse in an outpatient surgical setting is assessing a client scheduled for cataract removal. The nurse would expect to find that the client has (Select all that apply) a. a shadow across the visual field. b. better vision in low light. c. blurred vision, photophobia, and glare. d. nausea and vomiting, worse with eye movements. e. sudden onset of acute eye pain.

ANS: B, C A cataract is an opacity of the lens. Classic manifestations are blurred or double vision, photophobia, and glare. Clients usually see better in low light. A shadow across the visual field is characteristic of retinal detachment. Nausea and vomiting, and acute eye pain often accompany acute angle-closure glaucoma, although the nausea may or may not be worse with eye movement.

In the client with medulla injury, the nurse monitors for which clinical manifestations secondary to damage to cranial nerves that emerge from the medulla? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Blink reflex d. Visual changes e. Inability to shrug shoulders f. Loss of gag reflex

ANS: B, E, F Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic).

A client with acute-angle glaucoma has several medications ordered. Which medication will the nurse question? (Select all that apply.) a. Acetazolamide (Diamox) b. Pilocarpine (Pilocar) c. Atropine (Isopto Atropine) d. Latanoprost (Xalatan) e. Timolol (Timoptic) f. Epinephrine

ANS: C, F Atropine and epinephrine are mydriatics, which decrease the outflow of aqueous humor, resulting in increased intraocular pressure (IOP). Diamox is a carbonic anhydrase inhibitor that decreases the formation of aqueous humor. Pilocar is a miotic that enhances outflow of aqueous humor. Xalatan is a prostaglandin agonist that improves outflow, and Timoptic is a beta blocker that decreases the formation of aqueous humor. All these help decrease IOP.

The nurse is assessing a client for the possibility of a lens opacity. Which assessment finding confirms this problem?

Absence of a red reflex

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What clinical manifestations would you expect this patient to exhibit?

Absent or decreased reflexes Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.

A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in ICP. What nursing intervention would be appropriate for this patient?

Absolute bed rest in a quiet nonstimulating environment

The client is to have cataract surgery in a few hours. Which drug should the nurse be prepared to administer for the purpose of reducing intraocular pressure?

Acetazolamide (Diamox) Acetazolamide is a carbonic anhydrase inhibitor and decreases the secretion of aqueous humor from the zonules of the eye, resulting in a decreased intraocular pressure.

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first?

Administer 5% hypertonic saline intravenously.

The Paramedics have brought an intubated patient to the emergency department following a head injury due to acceleration-deceleration motor vehicle accident. Increased intracranial pressure (ICP) is suspected. An appropriate nursing intervention would include what?

Administer antipyretics on a prn basis. A hyperthermic state causes increased ICP

When a patient experiences a generalized tonic-clonic seizure in the emergency department after a head injury, all of the following orders are received. Which one will the nurse implement first?

Administer midazolam (Versed). To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines

The client complains of eye pain and has nausea 2 hours after cataract surgery. Which is the nurse's priority intervention?

Administering oral glycerin (Osmoglyn) The only action that would lessen the intraocular pressure is the administration of oral glycerin (Osmoglyn).

During the health history, the client tells the nurse about all the following health problems. Which one increases the risk for impaired hearing?

Allergic rhinitis Allergic rhinitis can result in the collection of serous fluid in the middle ear. This fluid prevents full movement of the tympanic membrane and reduces conduction of sound waves.

A patient with a skull fracture was admitted unconscious, became conscious, and has since moved into unconsciousness again. This patient is demonstrating findings indicative of:

An epidural hematoma Approximately half of the patients who suffer this injury demonstrate the classic presentation of an initial loss of consciousness followed by a lucid interval and then a sudden reloss of consciousness with rapid deterioration in neurologic status.

A nurse caring for a patient who is being discharged home after a stroke is preparing patient/family teaching. What topics would be most important for the nurse to include in the teaching? (Mark all that apply.) A) Stroke prevention B) The rehabilitation process C) Causes of stroke D) Adequate nutrition E) Exercise

Ans: A, B, C Patient and family education is a fundamental component of rehabilitation. The nurse provides teaching about stroke, its causes and prevention, and the rehabilitation process. While all answers are eventually included in family teaching the most important are stroke cause and prevention and the rehabilitation process.

When caring for a patient with a neurologic dysfunction, what complications must the nurse monitor for? (Mark all that apply.) A) Contractures B) Interrupted family processes C) Pressure ulcer D) DVT E) Pneumonia

Ans: A, C, D, E Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. Interrupted family processes is a nursing diagnosis, not a possible complication.

As a member of the stroke team at your institution, you know that the contraindications for thrombolytic therapy include what? (Mark all that apply.) A) INR above 1.0 B) Recent intracranial pathology C) Symptom onset greater than 2 hours prior to admission D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission

Ans: B, D, E Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3 hours before admission, a patient who is anticoagulated (with an INR above 1.7), or a patient who has recently had any type of intracranial pathology (eg, previous stroke, head injury, trauma). Therefore options A and C are incorrect.

When reviewing the results of a patient's cerebrospinal fluid analysis, the nurse will notify the health care provider about a. pH of 7.35. b. white blood cell count (WBC) of 4/ml (0.004/L). c. protein 30 mg/dl (0.30 g/L). d. glucose 30 mg/dl (1.7 mmol/L).

Answer: D The glucose level is low. The pH, WBCs, and protein values are normal.

During initial assessment of a client who has just suffered a head injury, a nurse notes that the pupils have an ovoid appearance. What is the nurse's best first action?

Anticipate intervention for increased ICP after notifying the physician. The change in pupil appearance from round to ovoid (mid-stage between normal and dilated) is an indication of increase intracranial pressure

A patient schedules annual testing for glaucoma with the ophthalmologist. Which information will be included when teaching the patient about routine glaucoma testing?

Application of a Tono-pen to the cornea of the eye will be needed. Glaucoma is caused by an increase in intraocular pressure, which would be measured using the Tono-pen

The client is 6 hours postoperative from a craniotomy. When monitoring vital signs, a nurse observes the client to have periorbital edema and ecchymosis around both eyes. What is the nurse's best first action?

Apply an ice pack to the affected area. Periorbital edema and ecchymosis are expected after a craniotomy. The nurse attempts to increase the client's comfort by reducing the swelling with application of ice.

A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?

Applying intermittent pneumatic compression stockings The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for deep vein thrombosis (DVT).

Penumbra

Around the core area of ischemia is a border zone of reduced blood flow called the penumbra, where ischemia is potentially reversible. If adequate blood flow can be restored early (i.e., within 3 hours) and the ischemic cascade can be interrupted, there may be less brain damage and less neurologic function lost (Lewis 1461)

Which nursing assessment would have highest priority for early airway management of a trauma patient?

Ask the patient to state his name. If the patient can state his name audibly then the airway is patent

A client with mastoiditis is admitted to your unit prior to undergoing a radical mastoidectomy. What do you know is a nursing priority postoperatively?

Assessing for mouth droop and decreased lateral eye gaze

You have a patient with an altered level of consciousness. What would be your first action when assessing this patient?

Assessing the verbal response

A preceptor is discussing stroke with the new nurse on the unit. What cardiac dysrhythmia would the preceptor tell the new nurse is associated with cardiogenic embolic strokes?

Atrial fibrillation

A client with a history of complex partial seizures presents to the clinic for a follow-up visit. What manifestations of this type of seizure disorder might the nurse observe in this client?

Automatisms Automatisms are characteristic of partial seizures. These behaviors consist of lip smacking, patting, and picking at clothing.

The client has a hearing loss at the 30-decibel (dB) level of intensity. The nurse should do which of the following?

Avoid whispering. Clients who are able to hear at intensities above the 30-dB range can hear normal conversational speech without a hearing aid, but will not be able to hear whispers.

As the nurse caring for a spinal cord injured patient, you are performing your initial shift assessment. You note muscle spasticity. What medication would you expect to be ordered to control this clinical manifestation?

Baclofen (Lioresal) Baclofen is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal cord injury.

Patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture?

Battle's sign An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture.

Low Vision Value

Between 20/70-20/200 Ex: 20/100

Normal ICP

Between 5-15 mm Hg

A nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. What response to this assessment should the nurse expect to elicit?

Bilateral hypoactive reflexes of the knees and Achilles tendons Long-standing diabetes mellitus causes peripheral neuropathy

A patient who has sustained a basal skull fracture is admitted to your unit. You know that the patient should be observed for what?

Bleeding from the ears

A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

Blood pressure 156/60, pulse 60, respirations 14 Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP.

What is the major disadvantage of ophthalmologic ointments?

Blurred vision

Which subjective clinical manifestation alerts the nurse to the possible presence of a cataract?

Blurred vision and reduced color perception

Which client response during assessment of the eye and vision indicate to the nurse that the client has normal accommodation?

Both pupils constrict when focusing on an object being moved in toward the nose.

Decerebrate posturing (abnormal extension) indicates dysfunction in which area of the central nervous system?

Brainstem

A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. If the nurse suspects cerebral herniation the most appropriate intervention would be to

Briefly hyperventilate the patient Hyperventilating the patient lowers the ICP by lowering the PaCO2 that is causing vasoconstriction of the cerebral blood vessels and reducing cerebral blood flow.

A client who has had a stroke appears to understand words that are spoken but cannot verbally respond. The nurse clarifies that this type of aphasia is

Broca's. Broca's (expressive or motor) aphasia affects speech production as a result of an infarction in the frontal lobe of the brain.

CPP Calculation

CPP = MAP - ICP MAP=DBP+1/3(SBP−DBP)orSBP+2(DBP)3 Example: Systemic blood pressure = 122/84 mm Hg MAP = 97 mm Hg ICP = 12 mm Hg CPP = 85 mm Hg CPP, Cerebral perfusion pressure; DBP, diastolic blood pressure; ICP, intracranial pressure; MAP, mean arterial pressure; SBP, systolic blood pressure (Lewis 1426)

The nurse is caring for a severely brain injured patient. A family member requests information regarding signs of brain death. The nurse knows that what diagnostic test will be done to confirm brain death?

Cerebral blood flow studies The three cardinal signs of brain death upon clinical examination are coma, the absence of brainstem reflexes, and apnea. Adjunctive tests such as EEG and cerebral blood flow studies are often used to confirm brain death.

After a subarachnoid hemorrhage, the patient is found to have a serum sodium of less than 135 mEq/L for greater than 24 hours. What would this patient be evaluated for?

Cerebral salt-wasting syndrome

What process causes brain damage resulting from increased intracranial pressure related to cerebral edema?

Cerebral tissue hypoxia and ischemia from compression of blood vessels

The nurse on the med-surg floor is reviewing discharge instructions with a patient who has a history of glaucoma. Which classification of drugs on the patient's discharge instructions is used to treat the patient's glaucoma?

Cholinergics Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork.

A patient is admitted to the unit with irreversible tissue damage and persistent tympanic membrane perforation. What is this?

Chronic otitis media

A 13-year-old was brought to the emergency department, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?

Classic concussion A classic concussion is an injury that results in a loss of consciousness; characteristically, this usually lasts less than 6 hours.

Which of the following laboratory values and observations noted on testing a client's CSF is indicative of viral meningitis?

Clear, increased protein level; normal glucose level Viral meningitis does not cause cloudiness or increased turbidity of the CSF. There are slightly increased protein and normal glucose levels. In bacterial meningitis, the presence of bacteria and white blood cells cause the fluid to be cloudy

A client has paralysis of the right medial rectus muscle of the right eye. Which assessment finding assists the nurse in validating this diagnosis?

Client is unable to turn the eye in toward the nose.

The client is receiving warfarin therapy after a thrombotic stroke. Which of the following international normalized ratios (INR) indicates that anticoagulation is adequate?

Client's INR is 2.0 to 3.0. Therapeutic INR values for clients receiving warfarin should range between 2 and 3 times the control value.

Following surgery for a pituitary tumor, when the client develops diabetes insipidus, the nurse explains that the drug that will be helpful to remedy the manifestations is

Clients who have diabetes insipidus after pituitary surgery often require IV vasopressin (Pitressin) or desmopressin (DDAVP).

The cerebrospinal (CSF) fluid laboratory finding the nurse would expect in a client with bacterial meningitis is

Clients with bacterial meningitis show the following: elevated CSF pressures, elevated CSF protein, decreased CSF glucose, and usually increased cell count with predominantly polymorphonuclear leukocytes.

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to "beat" two to three times before setting into a resting position. How would the nurse document this finding?

Clonus

The client has a sensorineural hearing loss. Which assistive device, technique, or corrective procedure is most likely to increase this client's hearing?

Cochlear implant Hearing aids and tympanoplasty can improve the hearing of a person with a conductive hearing loss but are of minimal benefit for sensorineural hearing loss. A cochlear implant can restore some degree of hearing for clients with sensorineural hearing loss.

A patient with hearing loss asks the nurse about the use of a cochlear implant. Which information will the nurse include when replying to the patient?

Cochlear implants require training in order to receive the full benefit. Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit

Glycerol Test

Collaborative care of Ménière's disease (Table 22-16) includes diagnostic tests to rule out other causes of the symptoms (Lewis 427)

A school nurse is called to the playground where a 6-year-old girl has fallen off the slide. When the nurse gets to the playground the girl is exhibiting jerking motions in her left arm and leg. The girl is unconscious. How would the nurse document the girl's activity in her chart at school?

Complex partial seizure In a simple partial seizure, consciousness remains intact, whereas in a complex partial seizure, consciousness is impaired.

A 78-year-old male patient has been admitted to your unit with neurological deficits of unknown origin. The nurse caring for this patient knows that dulled tactile sensation in this patient is a normal finding. What could this dulled tactile sensation cause?

Confusion about body position There may be difficulty in identifying objects by touch, because fewer tactile cues are received from the bottom of the feet and the person may become confused about body position and location.

A patient is being given a medication that stimulates her parasympathetic system. What is an effect of parasympathetic stimulation?

Constricted pupils Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

A patient with a brain tumor is prescribed an antiseizure medication. The nurse realizes that the purpose of this medication will be to

Control the onset of seizure activity.

TEMPORAL

Controls hearing, speech, and memory

PARIETAL

Controls integration of sensory information; awareness of body parts; and interpretation of touch, pressure, and pain

OCCIPITAL

Controls interpretation of visual stimuli

FRONTAL

Controls voluntary motor function, cognitive function, expressive language

A patient is demonstrating neurologic changes consistent with increasing intracranial pressure. For which primary causes of this pressure increase will the nurse assess at this time? Standard Text: Select all that apply. 1. Cerebral hemorrhage 2. Ischemic stroke 3. Airway obstruction 4. Drop in blood pressure 5. Electrolyte imbalance

Correct Answer: 1,2 Rationale 1: Cerebral hemorrhage is a primary cause of increased intracranial pressure. Rationale 2: Ischemic stroke is a primary cause of increased intracranial pressure. Rationale 3: Airway obstruction is a secondary cause of increased intracranial pressure. Rationale 4: Hypotension is a secondary cause of increased intracranial pressure. Rationale 5: Electrolyte imbalances indicate metabolic disorders, which are secondary causes of increased intracranial pressure.

The nurse is caring for a patient who sustained head and abdominal injuries from a motor vehicle crash. While the nurse is inserting a nasogastric tube to decompress the stomach, the patient begins to cough and gag. What cranial nerves did the nurse inadvertently assess when inserting the nasogastric tube into the patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. IX (glossopharyngeal) 2. X (vagus) 3. V (trigeminal) 4. VII (facial) 5. III (oculomotor)

Correct Answer: 1,2 Rationale 1: This nerve is intact when the patient exhibits the cough and gag reflex. Rationale 2: This nerve is intact when the patient exhibits the cough and gag reflex. Rationale 3: This nerve is used to assess for the corneal reflex. Rationale 4: This nerve is used to assess for the corneal reflex. Rationale 5: This nerve is used to assess pupillary response

A patient with a traumatic brain injury is diagnosed with an acute subdural hematoma. What would the nurse be more likely to assess in this patient than in one who had experienced a chronic subdural hematoma? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Loss of consciousness 2. Hemiparesis 3. Dysphagia 4. Confusion 5. Headache

Correct Answer: 1,2,3 Rationale 1: Loss of consciousness is a manifestation of acute subdural hematoma. Rationale 2: Hemiparesis is a manifestation of acute subdural hematoma. Rationale 3: Dysphagia is a manifestation of acute subdural hematoma. Rationale 4: Confusion is a manifestation of chronic subdural hematoma. Rationale 5: Headache is a manifestation of chronic subdural hematoma

A patient being treated for a cardiac dysrhythmia is demonstrating signs of an ischemic stroke. What assessment findings alerted the nurse to the development of this complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Garbled speech 2. Inability to see out of the right eye 3. Complaint of a sudden severe headache 4. New onset of left arm and leg weakness 5. Sudden onset of pain and swelling in one lower extremity limb

Correct Answer: 1,2,3,4 Rationale 1: Difficulty understanding speech or speaking is symptom of an ischemic stroke. Rationale 2: The inability to see out of one eye is a symptom of an ischemic stroke. Rationale 3: A new onset of a sudden severe headache is a symptom of an ischemic stroke. Rationale 4: The onset of weakness on one side of the body is a symptom of an ischemic stroke. Rationale 5: The sudden onset of pain and swelling in one lower extremity limb is not a symptom of ischemic stroke but rather a venous thromboembolism.

A patient is diagnosed with meningitis that developed after experiencing otitis media. What will the nurse most likely assess in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Fever 2. Stiff neck 3. Confusion 4. Photophobia 5. Palpitations

Correct Answer: 1,2,3,4 Rationale 1: Fever is a manifestation of meningitis. Rationale 2: A stiff neck or nuchal rigidity is a manifestation of meningitis. Rationale 3: A change in mental status is a manifestation of meningitis. Rationale 4: Photophobia is a manifestation of meningitis. Rationale 5: Palpitations are not manifestations of meningitis.

A patient has been receiving treatment for status epilepticus for the last 20 minutes. What will the nurse prepare to implement to help the patient at this time? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Prepare for emergency intubation. 2. Insert an indwelling urinary catheter. 3. Monitor body temperature. 4. Obtain an order for a bedside electroencephalogram. 5. Insert an intravenous access line.

Correct Answer: 1,2,3,4 Rationale 1: If the seizure continues beyond 20 to 30 minutes, the patient should be intubated. Rationale 2: If the seizure continues beyond 20 to 30 minutes, the patient should have an indwelling urinary catheter inserted. Rationale 3: If the seizure continues beyond 20 to 30 minutes, the nurse should monitor the patient's body temperature. Rationale 4: If the seizure continues beyond 20 to 30 minutes, an electroencephalogram should be obtained. Rationale 5: An intravenous access line would have been placed earlier for the administration of intravenous medication.

The nurse is teaching a patient, recovering from a mild brain injury, about manifestations to expect during the recovery process. What will the nurse instruct this patient to expect while recuperating from this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Headache 2. Dizziness 3. Fatigue 4. Memory loss 5. Nausea

Correct Answer: 1,2,3,4 Rationale 1: Problems experienced by patients with mild brain injuries include headache. Rationale 2: Problems experienced by patients with mild brain injuries include dizziness. Rationale 3: Problems experienced by patients with mild brain injuries include fatigue. Rationale 4: Problems experienced by patients with mild brain injuries include memory loss. Rationale 5: Nausea is not a problem experienced by patients with mild brain injuries.

When administering hypertonic saline to the patient with increased intracranial pressure (ICP), the nurse would: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Monitor the patient for renal failure and pulmonary edema. 2. Administer any concentrations greater than 2% through a central line. 3. Monitor serum sodium levels frequently during administration. 4. Expect the patient's neurologic status and ICP will begin to improve within 15 minutes following administration. 5. Monitor the patient's serum osmolarity every 24 hours.

Correct Answer: 1,2,3,4 Rationale 1: Renal failure and pulmonary edema can occur from this fluid. Rationale 2: A solution greater than 2% should be administered through a central line. Rationale 3: Serum sodium levels should be frequently monitored during the administration of this fluid. Rationale 4: The patient's neurologic status and intracranial pressure level will improve within 15 minutes following the administration of this fluid. Rationale 5: Serum osmolarity should be measured at least every 12 hours and maintained at less than 320 mOsm/L.

Which is the most important precaution for the nurse to teach the client being treated for posterior uveitis?

Correct technique for eyedrop instillation Treatment of posterior uveitis is symptomatic, with eyedrops to dilate the pupil and decrease the inflammatory response.

The camp nurse is caring for a patient who is complaining of bilateral eye pain after a campfire log exploded, sending sparks into the patient's eyes. Which of these actions will the nurse take first?

Cover the eyes with dry sterile patches and protective eye shields. Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the eyes from further injury by covering them with dry sterile dressings and protective shields

A nurse should assess for hearing loss in the client with

Cystic fibrosis, who is receiving high-dose tobramycin therapy

Which of the following effects does hypotension have on the neurologic system?

Decreased perfusion of cerebral tissue

The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor?

Dexamethasone

The client with a brain tumor has been admitted to the hospital because of increasing cerebral edema. What medication for the treatment of this problem should the nurse prepare to administer?

Dexamethasone is given to control cerebral edema secondary to brain tumors.

A client is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière's disease. What question is it most important for the nurse to ask the client in preparation for this test?

Do you currently take sedatives, tranquilizers, or antihistamines on a regular basis? Sedatives, tranquilizers, and antihistamines suppress the vestibular system in the inner ear, leading to unreliable test results.

The nurse assesses a patient's GCS score to be 3. What is the best interpretation by the nurse?

Does not open eyes, no motor response, and no verbal response

A nurse is preparing to administer mannitol (Osmitrol) to a client with a severe head injury. What precaution should the nurse take before the administration of this medication?

Draw up the medication using a filtered needle. Mannitol (Osmitrol) must be drawn up using a filtered needle to eliminate microscopic crystals.

For which type of foreign object in the ear canal is irrigation contraindicated?

Dried beans Irrigating the ear canal containing dried beans or any other vegetable matter is contraindicated because the irrigating fluid can cause the matter to swell and become more impacted.

A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?

EEG

The nurse suspects an epidural hematoma. Based on the knowledge of the progression of this type of hematoma, the nurse prepares for which priority intervention?

Emergency craniotomy Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding

Which type of hematoma results from traumatic injury involving the middle meningeal artery?

Epidural Traumatic injury to the middle meningeal artery is the most common cause of epidural hematoma.

A 64-year-old patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate?

Explaining that this is an expected adverse effect Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. Blurred vision lasting 1 to 2 hours after instilling the eyedrops is an expected adverse effect

The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient what characteristic symptom would the nurse expect to find?

Flashing lights in the visual field

When caring for a patient with increased ICP the nurse must monitor for possible secondary complications. One possible complication of increased ICP is SIADH. What nursing interventions would the nurse initiate if the patient developed SIADH?

Fluid restriction

The nurse explains that an epidural blood patch may be used to treat a headache that has resulted from a

For a post-lumbar puncture headache, an epidural blood patch accomplished by injection of 15 ml of autologous whole blood rarely fails for those who do not respond to caffeine.

The client has experienced a permanent conductive hearing loss. This type of hearing loss is most commonly associated with which of the following?

Frequent episodes of otitis media as a child

When performing the client's physical assessment, the nurse notes that the client has conductive hearing loss. Which finding does the nurse expect to see in the client's medical history?

Frequent episodes of otitis media during childhood Chronic middle ear infections can thicken the tympanic membrane and lead to conductive hearing loss.

Cytomegalovirus (CMV) is the most common cause of retinal inflammation in patients with AIDS. What drug, surgically implanted, is used for the acute stage of CMV retinitis?

Ganciclovir

The client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this seizure activity?

Generalized tonic-clonic seizure Seizure activity that begins with a stiffening of the arms and legs, followed by a loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure.

A patient presents at the emergency department after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this patient?

Generously flush the affected eye with normal saline or water.

What technique should the nurse use to elicit the Brudzinski reflex in a client being assessed for meningitis?

Gently flex the client's head and neck onto the chest and observe for flexion of the hips and knees

A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to your unit. You would be correct in assessing for what adverse effect of this therapy?

Gingivival hyperplasia

A patient having an eye examination is undergoing a brightness acuity test. What is the ophthalmologist testing for?

Glare

On otoscopy, what middle ear mass is seen as a red blemish behind the tympanic membrane?

Glomus tympanicum

The nurse is preparing to administer a medication to a patient to decrease the cerebral edema caused by a brain tumor. This medication is most likely a(n):

Glucocorticoid Glucocorticoid therapy with dexamethasone has been the standard treatment for tumor-associated edema.

When examining the client's external ear, a nurse palpates painless nodules on the pinna. The nurse should inquire about history of which of the following?

Gout, sun or chemical exposure, arthritis

A 6-month-old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the nurse is aware that the tympanic membrane should be what color in a healthy ear?

Gray The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear canal

The nurse assesses for the most common manifestations of a post-traumatic brain abscess, which are

Headache and lethargy are the most common manifestations. Manifestations of infection are present about half the time.

A nurse is caring for a patient diagnosed with Ménière's disease. While completing a neurological exam on the patient the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what?

Hearing and equilibrium

An 82-year-old male is admitted for observation after a fall. What is this patient at increased risk for?

Hematoma

A client is admitted to the intensive care unit after incurring a basilar skull fracture. What complication from this injury should the nurse remain alert for?

Hemorrhage

Ménière's Disease Diet

Hydrops diet: restriction of sodium, caffeine, nicotine, alcohol, and foods with monosodium glutamate (MSG) (Lewis 428)

A patient is diagnosed with an intracerebral hemorrhage. What is the most common cause of this disorder?

Hypertension

The nurse is caring for a patient with increased intracranial pressure (IICP) caused by a traumatic brain injury. Which of the following clinical manifestations would indicate that the patient is experiencing increased brain compression causing brainstem damage?

Hyperthermia Hyperthermia increases the metabolic demands of the brain and may indicate brainstem damage

What might a patient develop if intravenous phenytoin (Dilantin) was administered faster than 50 mg/minute?

Hypotension Phenytoin is administered no faster than 25 to 50 mg/min, because faster administration may result in bradycardia, hypotension, heart block, and ventricular fibrillation.

A patient in the operating room goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following?

Hypothalamus

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse?

ICP is high; CPP is normal The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range

Which of the following deficits should the nurse expect to find in a client who has experienced an injury to the frontal lobe of the brain?

Impaired judgment The frontal lobe is responsible for many functions; among them are judgment, reasoning, voluntary eye movement, and motor functions.

The client has experienced a stroke to the right cerebral hemisphere. Which of the following deficits should the nurse expect this client to manifest?

Impaired proprioception A stroke to the right cerebral hemisphere causes impaired visual and spacial awareness. The client may present with impaired proprioception and be disoriented as to time and place.

The nurse is caring for a mechanically ventilated, brain injured patient. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow?

Increased cerebral blood volume due to vessel dilation Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume.

The nurse has admitted a new patient to the unit. One of the patient's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system?

Increased heart rate Sympathetic effects include an increased rate and force of the heartbeat

When assessing a patient, the nurse notes early signs of increasing ICP. What sign or symptom might the nurse have noted?

Increased respiratory effort The nurse assesses for and immediately reports any of the following early signs or symptoms of increasing ICP: disorientation, restlessness, increased respiratory effort, purposeless movements, and mental confusion

Which nursing diagnosis is considered a priority for a client who experienced a stroke 24 hours ago?

Ineffective Tissue Perfusion Clients who have experienced a stroke are most at risk of increased intracranial pressure (ICP) within the first 72 hours of onset.

When irrigating the external ear canals of an older adult client, which nursing intervention would be used to assist in the removal of dry cerumen?

Instilling oil into the canals 8 hours before irrigation

The nurse is caring for an older client whose ear canals are impacted with hard cerumen. Which is the best intervention for the nurse to implement to facilitate removal of the cerumen?

Instruct the client to put a few drops of mineral oil into each ear every evening and schedule the irrigation for 3 days later. Softening hard cerumen with mineral oil for 3 days prior to irrigation will facilitate removal from the ear canal

The nurse is caring for a patient on the neurologic unit who is in status epilepticus. What medications does the nurse know may be given to halt the seizure immediately?

Intravenous diazepam (Valium) Medical management of status epilepticus includes intravenous diazepam (Valium) and intravenous lorazepam (Ativan) given slowly in an attempt to halt seizures immediately

Which of the following is the correct rationale for monitoring peripheral oxygenation saturation in the client with encephalitis?

It will alert the clinician to hypoxia and possible secondary brain damage.

The nurse is assessing a 48-year-old patient for presbyopia. Which equipment will the nurse need to obtain prior to the examination?

Jaeger chart Presbyopia is the normal loss of near vision that occurs with age and is assessed using a Jaeger chart.

A patient with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan?

Keep the patient's room darkened. A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's disease

You are the night shift nurse caring for a patient who had a craniotomy that morning. The patient becomes disoriented, can't sleep, and begins to hallucinate. The nurse knows that the patient is exhibiting symptoms of what?

Korsakoff's syndrome Korsakoff's syndrome is a disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations.

A patient presents to the emergency department complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly can't hear very well. What would the nurse suspect the patient's diagnosis will be?

Labyrinthitis Labyrinthitis is characterized by a sudden onset of incapacitating vertigo, usually with nausea and vomiting, various degrees of hearing loss, and possibly tinnitus

Which of the following is administered before suctioning to prevent associated increases in intracranial pressure?

Lidocaine Lidocaine is used to blunt the effects of tracheal stimulation on intracranial pressure and must be administered no longer than 5 minutes before suctioning

What would be the effect on refraction and vision if the client did not have a lens in one eye?

Light waves would be inadequately refracted and the image would not fall properly on the retina, causing the client to have extremely poor near vision.

A patient with a seizure disorder is presenting having a generalized seizure. An appropriate nursing intervention during the seizure would include what?

Loosen the patient's restrictive clothing.

The client is experiencing status epilepticus. Which of the following drugs should the nurse have ready to administer?

Lorazepam Initially, intravenous lorazepam is administered to stop motor movements; this is followed by administration of phenytoin.

You are caring for a patient with an upper motor neuron lesion. What clinical manifestations would you expect this patient to exhibit?

Loss of voluntary control

You have admitted a patient to the Neurolog Intensive Care Unit with a brainstem herniation. The patient is now exhibiting an altered level of consciousness. The nurse has determined that the patient's mean arterial pressure (MAP) is 60 with an intracranial pressure (ICP) reading of 5 mm Hg. The nurse would be correct in determining the cerebral perfusion pressure (CPP) as which of the following values?

Low The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. A lower than normal CPP indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion.

After a routine eye examination the patient is told he has a best corrected visual acuity (BCVA) of 20/100 in his better eye. This means the patient is considered to have what kind of vision?

Low vision

In what position should the nurse place the patient following a craniotomy with a supratentorial approach?

Maintain HOB elevated at 30 to 45 degrees

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. What goal is a priority for this patient?

Maintain and improve cerebral tissue perfusion.

A patient has been admitted to the ICU after being recently diagnosed with an aneurysm. Admission orders include aneurysm precautions. What aneurysm precaution will the nurse incorporate into the patient's plan of care?

Maintain the patient on complete bed rest.

A patient is hospitalized with acute angle-closure glaucoma. All the following orders are received. Which will the nurse implement first?

Mannitol (Osmitrol) 100 mg administered intravenously The most immediate concern for the patient is to lower intraocular pressure, which will occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol

The patient is 3 weeks postoperative and has come in for a routine postoperative check-up. The patient reports that for the past week he has been experiencing sharp, shooting pains on an intermittent basis in the operative area. From the patient's description of what has been happening, the nurse knows that the patient had what surgery?

Mastoidectomy After a mastoidectomy, for the next 2 to 3 weeks after surgery, the patient may experience sharp, shooting pains intermittently as the eustachian tube opens and allows air to enter the middle ear.

A patient with a history of chronic cancer pain is admitted to the hospital. When reviewing the patient's home medications, which of these will be of most concern to the admitting nurse?

Meperidine (Demerol) 25 mg every 4 hours Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods

When administering mannitol (Osmitrol) to a patient with increased intracranial pressure (ICP), the nurse would:

Monitor the osmolality of the blood every 4 to 6 hours if repeated doses are administered. Mannitol increases the osmolality of the blood with optimal osmolality between 300 and 320 mOsm

A patient with a traumatic brain injury is showing signs of having pain. What would be the medication of choice for this patient?

Morphine sulfate Morphine is most widely used because it has a high level of efficacy and safety yet is minimally sedating

Of the five types of tympanoplasties, which is designed to close a perforation in the tympanic membrane?

Myringoplasty

A patient admitted with bacterial meningitis and a temperature of 102° F has orders for all of these collaborative interventions. Which one should the nurse accomplish first?

Nasopharyngeal swab for culture and sensitivity cultures must be done before antibiotics are started

A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?

New floater in vision Cataract surgery increases the risk of retinal detachment and the patient must be instructed to notify the surgeon if new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness occurs. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days after surgery.

Ten days following surgery to clip an anterior communicating artery aneurysm, a transcranial Doppler detects cerebral vasospasm in a patient. The nurse anticipates which therapeutic intervention?

Nicardipine (Nimodipine) Nicardipine, a calcium channel blocker, has a vasodilatory effect.

To induce vasodilation for a client experiencing a Meniere's attack, the nurse should administer which of the following?

Nicotinic acid (Niaspan)

A nurse is planning preoperative teaching for a client with conductive hearing loss due to otosclerosis. The client is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the client's preoperative teaching?

Noticeable improvement in hearing may not be experienced for up to 6 weeks after surgery. Stapedectomy is a very successful procedure; approximately 95% of clients experience restoration of hearing. However, hearing returns gradually and can continue to improve for several weeks after surgery. It is important that the client understand this in order to prevent disappointment, anxiety, or depression after surgery

A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg. Which action by the nurse is appropriate?

Notify the health care provider about the assessments The patient's cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial BP

A client is admitted with a brain attack (stroke). On neurologic assessment, a nurse notes that the client's arms, wrists, and fingers have become flexed, and there is internal rotation and plantar flexion of the legs. What would be the nurse's best action?

Notify the health care team members. The client is demonstrating decorticate posturing that is seen with interruption in the corticospinal pathway

The nursing home resident with recurrent otitis media complains of new pain behind the ear. The area is red and swollen. What is the nurse's priority?

Notify the physician. The client's symptoms strongly suggest mastoiditis. Without appropriate antibiotic therapy, this condition can lead to hearing loss, meningitis, and more systemic infection.

What function would be altered if an individual's astroglial cells in the nervous system were impaired?

Nutrition and support of neurons Astroglial cells are responsible for the physical support and nourishment of the neurons.

Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 40 feet and the right eye can see at 20 feet what a person with normal vision can see at 50 feet. The nurse records these findings as visual acuity

OS 20/40; OD 20/50. OS is the abbreviation for left eye and OD is the abbreviation for right eye

The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of Ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis?

Obeys commands with appropriate motor responses.

When caring for a patient with altered level of consciousness the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII?

Observe for symmetry of facial movements, such as a smile.

A client is brought to the emergency room following a motor vehicle accident in which he sustained head trauma. The patient is complaining of blindness in the left eye. The nurse would be correct in documenting this abnormal finding as corresponding to which of the following cerebral lobes?

Occipital

How should the nurse position the television set for the nursing home resident who has macular degeneration in both eyes?

On either side of the client, because he or she no longer has central vision

The client has just returned from having surgery for a scleral buckling procedure to repair a large retinal detachment in the right eye. Sulfahexafluoride gas was used intraocularly. What postoperative position should the nurse use for this client?

On the abdomen with the affected eye up

A client was hit in the forehead by a fast-pitched softball 4 hours earlier in the day. Which clinical manifestations alert the nurse to the possibility of increased intracranial pressure?

Papilledema

The nursing instructor is teaching her students about monitoring a patient with increased ICP. What is a trend of ICP measurements over time an important indication of?

Patient's underlying status

A client relates that the vision in the left eye is greatly decreased from the day before. What will the nurse do first?

Perform an in-depth assessment. A client with a sudden or persistent loss of vision needs to have a complete history and assessment to identify the possible cause

Which action will the nurse take in order to assess the patient's visual field?

Perform the confrontation test

You are discharging a patient home after supratentorial removal of a pituitary mass. What medication would you expect to have ordered prophylactically for this patient?

Phenytoin Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have undergone supratentorial craniotomy because of the high risk of seizures after these procedures.

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface?

Pia mater

The nurse caring for a female patient diagnosed with an ischemic stroke knows that effective positioning of the patient is important. How might the nurse effectively position the patient?

Place the patient in prone position for 15 to 30 minutes several times a day.

A female patient is diagnosed with a right stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties?

Place the patient's extremities where she can see them.

You are caring for a patient recovering from an ischemic stroke. You know that it is important to monitor for potential complications. What are the potential complications after an ischemic stroke?

Pneumonia Potential complications of an ischemic stroke include decreased cerebral blood flow due to increased ICP, inadequate oxygen delivery to the brain, and pneumonia

The client who has experienced a stroke has impairment of cranial nerve IX. What nursing intervention for nutrition should the nurse implement to prevent complications from this problem?

Position the client in the upright position with the head slightly forward and flexed during meals. Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment to this nerve are at great risk for aspiration.

After a large ischemic stroke, a possible complication is cerebral edema. What would nursing interventions during this period include?

Positioning to avoid hypoxia

A patient tells the nurse about an area on the arm that has been getting numb and "feels funny." This information is important because it will:

Possibly pinpoint the location of a brain tumor

The following orders are received for a patient who is unconscious after a head injury caused by an automobile accident. Which one should the nurse question?

Prepare the patient for lumbar puncture.

A patient diagnosed with TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done to what?

Prevent a stroke by removing atherosclerotic plaques blocking cerebral flow The main surgical procedure for select patients with TIAs is carotid endarterectomy

When caring for a patient with a traumatic brain injury, one of the goals the nurse might have with this patient is what?

Prevention of sleep deprivation The goals for the patient may include maintenance of a patent airway, adequate CPP, fluid and electrolyte balance, adequate nutritional status, prevention of secondary injury, maintenance of normal body temperature, maintenance of skin integrity, improvement of cognitive function, prevention of sleep deprivation, effective family coping, increased knowledge about the rehabilitation process, and absence of complications.

An important primary prevention activity the nurse could teach a community group for vision is (Select all that apply)

Primary prevention attempts to prevent disease processes before they start. Maintaining normal blood pressure can prevent hypertension-related eye problems. Wearing safety goggles and sunglasses can prevent eye injury. An annual eye exam is secondary prevention and taking glaucoma medications would be tertiary prevention

A patient with a penetrating traumatic head injury has a Glasgow Coma Scale of 9. The nurse realizes that what will most likely be implemented for this patient?

Prophylactic anticonvulsant therapy Risk factors for an early seizure after a traumatic brain injury include a Glasgow Coma Scale score of less than 10

The nurse has taken shift report on her patients and has been told that one patient has an ocular condition that has affected the rods in his eyes. Considering this information, what will the nurse do while caring for the patient?

Provide adequate lighting in the patient's room to assist the patient in achieving his best vision The nurse should provide adequate lighting in the patient's room, as the rods are mainly responsible for night vision or vision in low light. If the patient's rods are impaired, the patient will have difficulty seeing in dim light.

Psychogenic Seizures

Psychogenic seizures, also called pseudoseizures, resemble epileptic seizures but are actually psychiatric in origin. Psychogenic seizures are usually involuntary, and are a physical manifestation of a psychologic disturbance. They may be misdiagnosed as epilepsy.9 (Lewis 1494) Pt still talking

The nurse is caring for a client with otitis media. The client reports that the pain was severe during the night but was gone when he woke up in the morning. Which finding will the nurse expect to find during the client's physical assessment?

Purulent fluid is present in the ear canal. Spontaneous perforation of the tympanic membrane during acute otitis media relieves the pressure on middle ear structures and results in a sudden decrease or elimination of pain. Purulent drainage is often present in the ear canal as the fluid drains away from the tympanic membrane

You are admitting a patient to your unit who is scheduled to have an ossiculoplasty. What is this procedure expected to do?

Reconstruct the middle ear bones to restore hearing

Which clinical manifestation alerts the nurse to the possibility of a vitreous humor hemorrhage?

Red haze or floaters in the line of vision Mild seepage of blood into the vitreous humor causes the client's vision to have an overall red haze or floaters

During an otoscopic examination the nurse observes all the following in the client's ear. Which one requires physician collaboration?

Red tympanic membrane The tympanic membrane should be transparent and pearly gray. Redness indicates possible inflammation or infection. If bulging, there is risk for rupture scarring and permanent hearing loss.

Schwartz Sign

Reddish blush of the tympanum caused by the vascular and bony changes within the middle ear (Lewis 427)

Which of the following precautions are most appropriate in caring for the client diagnosed with meningococcal meningitis?

Respiratory precautions Meningeal meningitis is spread via saliva and droplets; caregivers should wear a mask when within 6 feet of the client and, of course, continue to use universal precautions.

The client with a chronic ear problem experiences vertigo frequently. Which action should the nurse suggest to reduce the sensations produced by vertigo?

Restrict head motions

An awake, alert patient arrives at the ED following a fall down a flight of stairs. The physician suspects a basilar skull fracture. Which assessment findings should the nurse anticipate?

Rhinorrhea and raccoon eyes

What is a priority nursing diagnosis for a client diagnosed with a sensorineural hearing loss?

Risk for Impaired Social Interaction related to decreased hearing

What is the priority nursing diagnosis for the client with Ménière's disease during an acute attack?

Risk for Injury related to impaired sense of balance

While reviewing the health history of a 72-year-old client experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What data is likely to be linked to the client's hearing deficit?

Routine use of quinine for management of leg cramps

What complication can the nurse expect to see manifested in a client with compression of the pituitary gland by a brain tumor?

SIADH

Your patient has been diagnosed with a loss of hearing related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition?

Sensorineural hearing loss

A nurse notes that the left arm of a client who has experienced a brain attack is in a contracted, fixed position. What complication of this position should the nurse be alert for?

Shoulder subluxation Hypertonia causing contracture or flaccidity can predispose the client to subluxation of the shoulder.

A nurse is giving going-home instructions about cardiac medications to the client who has experienced damage to the left temporal lobe of the brain. What adjustments should the nurse make for sensory deficits as a result of this injury?

Sit on the client's right side. The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and speak to the right ear.

The client recovering from a stroke has been prescribed clopidogrel (Plavix). What symptom or clinical manifestation should serve to alert the nurse to an adverse effect of this medication?

Spontaneous ecchymosis Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, or tarry stools.

What inner ear structure is affected when a client is diagnosed with otosclerosis?

Stapes

Which technique should a nurse use in performing the Rinne tuning fork test?

Start the fork vibrating and place the stem on the mastoid process. When the client no longer hears sound, move it in front of the pinna and ask the client to indicate when sound is no longer heard.

The nurse in a pediatric clinic is assessing a 1-year-old. In documenting a deviation from perfect ocular alignment, what term should the nurse use?

Strabismus

The client is 4 hours postoperative after a supratentorial craniotomy. What positioning would be most beneficial to this client?

Supine, with the head of the bed elevated to at least 30 degrees

A nurse has just received a client into the PACU after a tympanoplasty. What is a tympanoplasty is defined as?

Surgical repair of the eardrum

The nurse is caring for a client with Ménière's disease. The client is scheduled to go home tomorrow, so the nurse is preparing the client's discharge teaching. Dietary guidelines will be included. What foods should the client be instructed to limit or avoid?

Sweet pickles The client with Ménière's disease should avoid foods high in salt and/or sugar; sweet pickles are high in both. Any type of meat, fish, or poultry is permitted with the exception of canned or pickled varieties

The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques?

Test for air and bone conduction (Rinne)

The nurse notes a nursing assistant (NA) accomplishing all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by the NA indicates that the nurse should intervene immediately?

The NA turns on the patient's television. Watching television may exacerbate the symptoms of an acute attack of Ménière's disease.

A nurse is assessing the client with external otitis. Which of the following supports a worsening of the condition?

The auricular lymph nodes have increased in size during the past 24 hours

When a client is admitted to the hospital in an unconscious state following subarachnoid hemorrhage resulting from a ruptured intracranial aneurysm, the nurse anticipates that the manifestations that preceded the loss of consciousness were

The client experiences a sudden, severe headache, often accompanied by vomiting, often describing the headache as "the worst headache I have ever had."

A client demonstrates a positive Romberg's sign with eyes closed, but not with eyes open, during the course of the neurologic examination. What conclusion can the nurse make from this observation?

The client has difficulty with proprioception.

A nurse is taking the history of a client who presents with nausea, vomiting, fever, and a stiff neck. What information in this client's history would lead the nurse to suspect that the client has encephalitis?

The client has had a recent viral infection.

A client who experienced a minor hemorrhagic stroke from an aneurysm 1 week ago reports a severe headache accompanied by one episode of nausea and vomiting. What conclusion can be drawn from this information?

The client has manifestations of rebleeding. Clinical manifestations of rebleeding include severe headache, nausea and vomiting, a decreased level of consciousness, and other neurologic deficits.

The client has had a stroke, resulting in damage in Wernicke's area. How will this injury compromise the client's ability to communicate?

The client will be unable to comprehend spoken or written words. The client with damage to Wernicke's area cannot understand spoken or written words. If the client speaks, the language is meaningless, with the client using made-up words.

The client with a head injury is being given the neuromuscular blocking agent vecuronium while on mechanical ventilation. Pharmacologic paralysis should include which of the following considerations before implementation?

The drug does not induce analgesia or sedation.

A nursing student is doing a project on blindness to fulfill a class requirement. What should this student list as the most common causes of blindness and visual impairment among adults 40? (Mark all that apply.) A) Diabetic retinopathy D) Cytomegalovirus B) Trauma E) Glaucoma C) Macular degeneration

The most common causes of blindness and visual impairment among adults 40 years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and cataracts. Therefore trauma and cytomegalovirus are incorrect.

The charge nurse observes a nurse accomplishing all of these interventions for a patient who has just arrived in the post-anesthesia care unit after having right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene?

The nurse encourages the patient to cough. Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN?

The nursing assistant goes into the patient's room without a mask. Meningococcal meningitis is spread by respiratory secretions

The nurse obtains all these data when assessing a patient who has left-sided labyrinthitis. Which information should be reported immediately to the health care provider?

The patient complains about a stiff neck. A stiff neck is a symptom of meningitis, a possible complication of labyrinthitis

Which information obtained about a 75-year-old patient with new-onset seizures will be of concern to the nurse when the patient is being started on therapy with phenytoin (Dilantin)?

The patient has a history of chronic hepatitis C. Phenytoin is metabolized by the liver, and the patient's age and history of hepatitis may increase the risk for toxic effects

The nurse is assessing a patient who has recently been treated with amoxicillin (Amoxil) for acute otitis media of the right ear. Which assessment data obtained by the nurse is of most concern?

The patient has a temperature of 100.6° F. The fever indicates that the infection may not be resolved and the patient might need further antibiotic therapy.

When preparing to discharge a stroke patient home with his or her family, it is important to tell the family what?

The patient may be less interested in events than expected.

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?

The patient states, "I suddenly developed a terrible headache." A sudden-onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated.

The nurse at the outpatient surgery unit obtains all of this information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information has the most immediate implications for the patient's care?

The patient takes 3 antihypertensive medications.

When assessing a patient with bacterial meningitis, the nurse obtains all of the following information. Which should be reported immediately to the health care provider?

The patient's blood pressure is 86/42 mm Hg. Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors

The nursing instructor is discussing the difference between sensorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a client has. What Weber test results would indicate the presence of a sensorineural loss?

The sound is heard better in the ear in which hearing is better. A client with sensorineural hearing loss hears the sound better in the ear in which hearing is better. The Weber test assesses bone conduction of sound and is used for assessing unilateral hearing loss. A tuning fork is used. A client with normal hearing hears the sound equally in both ears or describes the sound as centered in the middle of the head. A client whose hearing loss is conductive hears the sound better in the affected ear.

The client with acute otitis media experiences a sudden decrease in ear pain. What does the nurse interpret this to mean?

The tympanic membrane has spontaneously perforated. Spontaneous perforation of the tympanic membrane during acute otitis media relieves the pressure on middle ear structures and results in a sudden decrease or elimination of pain.

The nurse notes all these assessment data when examining a patient's auditory canal and tympanic membrane. Which one is of most concern?

The tympanum is bluish-tinged. A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum

A client admitted the previous day for a suspected neurologic disorder becomes increasingly lethargic. What conclusion can the nurse draw from this observation?

There has been a decline in the client's central neurologic function.

Emergency treatment of coma of unknown cause includes rapid intravenous administration of which three agents?

Thiamine, glucose, narcotic antagonist When the cause of coma is not immediately known, intravenous administration of glucose is indicated to reverse possible hypoglycemic coma. Thiamine must be administered before the glucose because thiamine deficiency coma (Wernicke's encephalopathy) can be precipitated by the glucose load. Administration of a narcotic antagonist will reverse coma caused by narcotic overdose.

On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question?

Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg Since elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if MAP is >130 mm Hg or systolic pressure is >220 mm Hg

The nurse is assessing a patient's corneal reflex. The cranial nerve that is being assessed with this reflex is

Trigeminal Portions of the trigeminal and facial cranial nerves can be assessed by checking for a corneal reflex.

Which assessment finding alerts the nurse to the possibility that the client has a paralysis of the medial rectus muscle for the right eye? The client is unable to

Turn the right eye in toward the nose.

A client with aphasia presents to the emergency room with a suspected brain attack. What assessment data would lead the nurse to suspect this client has had a thrombotic stroke?

Two episodes of speech difficulties in the last month A thrombotic stroke is characterized by a gradual onset of symptoms that are often preceded by transient ischemic attacks causing a focal neurologic dysfunction

The nurse in the eye clinic is examining a 44-year-old patient who says "I see small spots that move around in front of my eyes." Which action will the nurse take first?

Use an ophthalmoscope to examine the posterior chamber and retina of the patient's eyes Although "floaters" are usually caused by vitreous liquefaction and are common in aging patients, they can be caused by hemorrhage into the vitreous humor or by retinal tears, so the nurse's first action will be to examine the retina and posterior chamber

When assessing a sedated patient, the nurse notes that the patient blinks only five or six times a minute. The nurse should plan to

Use artificial tears every hour Because blinking usually occurs about 15 times per minute, the patient is at risk for corneal drying and abrasions unless the eye is kept lubricated using artificial tears

What method of communication can be used with a hearing-impaired patient?

Using gestures

Which of the following structures form(s) the blood-brain barrier?

Vascular endothelial cells

A week after a client experienced a ruptured cerebral aneurysm, he becomes extremely indecisive and has frequent episodes of incontinence. The nurse reports these events as probable

Vasospasm, a complication of ruptured aneurysm, occurs 4 to 15 days following the rupture. The manifestations of vasospasm are dependent on the area of the brain involved.

Damage to the upper portion of the reticular activating system results in which condition?

Vegetative state

A patient develops cerebral vasospasm after a ruptured cerebral aneurysm. Collaborative treatment should be focused on:

Volume expansion

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Weber test

A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would indicate hearing loss?

Whisper test

Which is the best approach for the nurse to use to obtain a history from a client with sudden hearing loss?

Write out the questions for the client to answer.

The nurse caring for a client after keratoplasty (corneal transplantation) would assess the client for possible graft rejection, as indicated by

a cloudy, swollen cornea.

An important age-related consideration the nurse should include in the care plan for an elderly client with a seizure disorder is

a decreased serum albumin level can increase the free plasma level of medications. Protein-calorie malnutrition is common among elders and the subsequent decreased serum albumin level can lead to increased plasma levels of the drug, making them prone to drug toxicities. Many seizure medications do have multiple drug-drug interactions, but all are available for use in this population. The frequency of seizures being diagnosed in the elderly population is increasing.

Mr. G has suffered an ischemic stroke involving the left cerebral hemisphere. Which of the following neurologic abnormalities would you expect to see? Select all that apply. a. Aphasia b. Left visual field defect c. Difficulty balancing his checkbook d. Ataxic gait e. Somnolence

a, c Rationale: While this type of stroke can affect speech and cognitive functions such as addition or subtraction, there is usually not a change in LOC.

Mrs. M has been admitted with a subarachnoid hemorrhage (SAH). While reviewing her history you would expect to see which of the following prior symptoms? Select all that apply. a. Abrupt onset of severe headache b. Extended loss of consciousness c. Nausea and vomiting d. Photophobia e. Diffuse left-sided weakness

a, c, d Rationale: A key symptom in diagnosing SAH is the patients complaint of "the worst headache I've ever had." Loss of consciousness and weakness are not necessarily present at onset.

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's

ability to follow commands.

A patient in the intensive care unit continues to seizure after receiving Ativan. He currently has an intravenous infusion of Dextrose 5% and 0.45 Normal Saline infusing at a rate of 125 cc/hr. Which of the following should be done to assist with this patient's seizure activity?

administer Cerebyx as prescribed Even though intravenous Ativan or Valium are effective in stopping the seizure 65-80% of the time, Cerebyx can be delivered faster, will not cause cardiac depression like Dilantin, and is compatible with dextrose intravenous solutions

When an object is placed in the hand of a patient with neurologic impairment during assessment, the patient is unable to recognize the placement. This is termed tactile

agnosia. Tactile agnosia, or astereognosis, is a perceptual disorder in which a patient is unable to recognize by touch alone an object that has been placed in his or her hand.

The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system (CNS) integrative function for a patient who has posttraumatic brain swelling, based on the finding of

apneustic breathing. Apneustic breathing is caused by loss of CNS integration in the pons and is not effective in maximizing gas exchange

To provide appropriate instructions to a client who has an ear wick inserted to facilitate medication administration for external otitis, the nurse would advise the client to

apply ear drops directly to the wick.

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to

ask simple questions that the patient can answer with "yes" or "no."

A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about

aspirin (Ecotrin). Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk

The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to

assess the patient for a possible head injury.

The nurse would assess the client with a history of TIAs for

ataxia and dysarthria. Manifestations of a TIA in the vertebrobasilar circulation include two or more of the following: vertigo, diplopia, dysphagia, dysarthria, and ataxia.

A patient being admitted to the hospital for a laparoscopic procedure tells the nurse about a history of glaucoma and the need to continue using prescribed eyedrops while hospitalized. For this patient, the nurse should question the preoperative order of

atropine sulfate 0.4 mg administered intramuscularly on call to the operating room (OR). Atropine is a parasympathetic blocker and will relax the iris, causing blockage of aqueous humor outflow and an increase in intraocular pressure.

A patient with chronic otitis media is scheduled for a tympanoplasty. Preoperatively the nurse teaches the patient that postoperative expectations include

avoidance of coughing or blowing the nose. Coughing or blowing the nose increases pressure in the eustachian tube and middle ear cavity and disrupts postoperative healing. There is no postoperative need for prolonged bed rest, elevation of the head, or continuous antibiotic irrigation

The nurse clarifies that a generalized seizure, unlike a partial seizure, involves

both hemispheres. A generalized seizure involves both hemispheres

The clinical manifestations of Cushing's triad are

bradycardia, systolic hypertension, and widening pulse pressure.

The nurse gives diazepam to a client in status epilepticus to stop the seizure because prolonged seizure activity can cause

brain injury. Prolonged seizure activity exhausts the body's supply of oxygen and glucose and can result in brain injury.

When assessing motor function, which of the following are correct? Select all that apply. a. The presence of a Babinski reflex is a normal finding in the adult. b. Lower extremity muscle tone is assessed by asking the patient to push or pull his foot against resistance. c. When using noxious stimuli to elicit a motor response, each limb is tested separately. d. Abnormal extension, or decerebrate posturing, indicates a less positive outcome than abnormal flexion. e. Evaluation of deep tendon reflexes (DTR) is an essential part of the nursing assessment.

c, d Rationale: The presence of a Babinski response in the adult is indicative of neurologic dysfunction; pushing or pulling against resistance tests muscle strength; DTR are not routinely checked by the critical care nurse during assessment

A nurse at the eye clinic advises all patients to wear sunglasses that protect the eyes from ultraviolet light because ultraviolet sunlight exposure is associated with the development of

cataracts

For consciousness to occur, there needs to be communication between the

cerebral cortex and reticular activation system.

The nurse should observe a client with bacterial meningitis for

changes in sensorium. Other general manifestations related to infection are also present, such as fever, tachycardia, headache, prostration, chills, fever, nausea, and vomiting. The client may be irritable at first, but as the infection progresses, the sensorium often becomes clouded, and coma may develop

The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to

check the nasal drainage for glucose with a Dextrostik or Testape.

When a client who underwent vestibular surgery complains of thirst, the nurse would avoid offering this client

cola. The client should avoid caffeine, which is a vestibular stimulant.

A score of 6 on the Glasgow Coma Scale (GCS) indicates

coma. Possible scores on the GCS range from 3 to 15. A score of 7 or less indicates coma

A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates a(n) _____ seizure

complex partial The initial symptoms of a complex partial seizure involve clinical manifestations that are localized to a particular part of the body or brain

When doing an ophthalmologic examination the nurse practitioner assesses papilledema, which the practitioner recognizes as an indication of:

compression of the second cranial nerve. Papilledema, the swelling of the optic disc, occurs when there is increased intracranial pressure. The optic nerve, cranial nerve II, is compressed as well as intracerebral vessels. The most probable cause of the pressure is brain tumor.

During the neurologic assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but does not respond to the nurse's questions. The nurse will suspect

damage to the frontal lobe. Expressive speech is controlled by Broca's area in the frontal lobe

When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as

decorticate posturing. Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing.

The nurse encourages a stroke victim by telling them that following a cerebrovascular accident (CVA) caused by thrombosis, the client's condition may improve after several days as a result of

decrease of edema in the area. The area of edema after ischemia may lead to temporary neurologic deficits. Edema may subside in a few hours or sometimes in several days, and the client may regain some function.

The nurse would explain that a nonsurgical approach to reduce the clinical manifestations of labyrinthitis is injection of an ototoxic drug into the middle ear to

destroy hair cells. The ototoxic drug destroys hair cells in the middle ear, which will reduce the manifestations of vertigo.

A patient with increased intracranial pressure is prescribed mannitol for the management of the increased pressure. The nurse realizes that this medication will

draw fluid from the edematous cerebral tissue into the vascular space.

The nurse, caring for a patient with neurological symptoms, should assess the patient for which of the following cluster of symptoms?

dysphagia, hemianopsia, hemiparesis

The nurse will hyperoxygenate a comatose client before suctioning the airway to decrease the risk of

dysrhythmias.

A patient who has bacterial meningitis and is disoriented and anxious has a nursing diagnosis of disturbed sensory perception related to decreased level of consciousness. An appropriate nursing intervention is to

encourage family members to remain at the bedside. Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside

The nurse obtaining the history of a client admitted for retinal detachment would note that the assessment finding not consistent with retinal detachment is the client's report of

experiencing intense pain. No pain is associated with detachment of the retina.

A patient arrives in the emergency department complaining of eye itching and pain caused by sleeping with contact lenses in place. To facilitate further examination of the eye, the nurse will anticipate the need for

fluorescein dye. Eye itching and pain suggest a possible corneal abrasion or ulcer, which can be visualized using fluorescein dye

A patient with seizure activity is receiving intravenous Dilantin. Which of the following should the nurse do when caring for this patient?

frequent monitoring of the injection site : Nursing care for a patient with an acute onset of seizures in the acute care setting includes observing the injection site frequently during administration of Phenytoin to prevent infiltration

The assessment the nurse documents that supports the finding of apraxia would be the client's inability to

get dressed independently. In apraxia the client cannot carry out a skilled act such as dressing in the absence of paralysis.

The nurse providing instructions to a client after ear surgery would tell the client that for the next 4 to 6 weeks, he/she should avoid

getting the ear wet. Keep the ear dry for 4 to 6 weeks after ear surgery. Avoid physical activity for 1 week and exercises or sports for 3 weeks. Blow the nose gently one side at a time and sneeze or cough with the mouth open for 1 week after surgery. Avoid airplane flights for the first week after surgery

A client with stroke has a nursing diagnosis of Impaired Verbal Communication and has specific difficulty in verbal expression. The most helpful strategy by the nurse would be to

give the client practice in repeating words after the nurse.

To assess the functioning of the optic nerve (CN II), the nurse should

have the patient read a magazine. The optic nerve is responsible for visual fields and visual acuity.

An 87-year-old patient has marked bilateral presbycusis. In performing a Rinne test on the patient, the nurse would anticipate that the patient

hears best when the tuning fork is placed next to the ear canal. The Rinne test is positive when air conduction is heard longer than bone conduction when a tuning fork is held against the mastoid bone (bone conduction) and then next to the ear canal (air conduction).

When the nurse caring for a client using an ICP monitor reads ICP as 20 mm Hg, the nurse would interpret this as

higher than normal.

A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates

impaired brain blood flow. The patient's CPP is 56, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death

A patient with cerebral infarction is experiencing an acceleration of symptoms. The nurse realizes that the death of the cerebral tissue is to due to which of the following?

increased concentration of sodium, chloride, and calcium in the brain cells

The most appropriate action that the nurse working at a camp would take to remove an insect from a camper's ear is

instill a few drops of mineral oil into the ear. For removal of a live insect, the ear canal is filled with mineral oil, lidocaine, or an ether-soaked cotton ball, not water, to kill or stupefy the insect. Water will cause the insect to swell, making it harder to remove.

In planning the care of a client with Crohn's disease for 10 years who has developed Sjögren's syndrome, the nurse would include

instilling lubricating eye drops frequently. Sjögren's syndrome is a condition is which tear secretion is reduced and is associated with several systemic disorders, including Crohn's disease. Frequent instillation of lubricating eye drops or ointment is effective in most cases. The other options are not treatments for this condition.

A nurse preparing to give mouth care to a comatose client should first place this client into the position of

lateral. When performing mouth care, place a comatose client in a lateral position to prevent aspiration.

A priority nursing intervention for a client in the emergency department with a suspected spinal cord injury is to

logroll the client. To prevent further injury to the client with a suspected spinal cord injury, the nurse (and other members of the health care team) should logroll the client. Mannitol is used for increased intracranial pressure. A tetanus booster may or may not be indicated, depending on if any skin was broken. While a thorough history is important, client safety is paramount.

The nurse caring for a client with a conductive hearing loss would enhance communication by facing the client and

lowering the pitch of the voice. Conduction hearing loss occurs in the higher frequencies. Loud, slow, or exaggerated movements may confuse the client.

During the admission assessment, the patient's spouse tells the nurse that the patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to

make eye contact with the patient and ask about any need for assistance. Making eye contact with a partially sighted patient allows the patient to hear the nurse more easily and allows the nurse to assess the patient's facial expressions

The nurse would instruct a client being taught to administer pilocarpine eye drops for glaucoma that the client

may have some blurring of vision after the drops are instilled.

The nurse would counsel clients who have experienced optic neuritis that they should see a physician regularly because they are at high risk for

multiple sclerosis. There is a close association between optic neuritis and multiple sclerosis.

The nursing action contraindicated in the care of a client with a severe basilar skull fracture is

nasal suctioning. Never suction the nasal passages in the client with a basilar skull fracture or facial fractures because the suction catheter can enter the cranial cavity.

The classic manifestations of meningitis are

nuchal rigidity (rigidity of the neck), Brudzinski's sign and Kernig's sign, and photophobia.

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include

oral administration of ticlopidine (Ticlid). The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke.

When the client experiences convulsive movement beginning in the hand and progressing to the arm and face, the nurse recognizes this as being consistent with

partial seizure with motor signs. The observation of the "jacksonian march" identifies this seizure activity as a partial seizure with motor signs

A young client has a perforation of the tympanic membrane that occurred while cleaning the ear with a pointed object. The nurse would advise that

perforations often heal spontaneously with no complications.

In reviewing a 50-year-old patient's medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess

peripheral vision. The patient's increased intraocular pressure indicates glaucoma, which decreases peripheral vision

A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. To help the patient learn to compensate for the deficit during the rehabilitation period, the nurse should

place objects necessary for activities of daily living on the patient's affected side. During the rehabilitation period, placing objects on the affected side will encourage the patient to use the scanning technique to visualize the affected side

A victim of an automobile accident was found unconscious at the scene of the accident but briefly regained consciousness during transport to the hospital. On admission, the Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse will anticipate the need to

prepare the patient for immediate craniotomy. The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation

A patient with a brain tumor is receiving radiation after having had a craniotomy. The nurse will explain that the purpose of the ordered methylprednisolone (Solu-Medrol) is to

prevent an increase in intracranial pressure (ICP). Radiation can lead to cerebral edema and rapid ICP increases and corticosteroids are administered to prevent this

The nurse is observing a student who is preparing to perform an ear examination of a 24-year-old patient. The nurse will need to intervene if the student

pulls the auricle of the ear down and backward. The auricle should be pulled up and back when assessing an adult.

The nurse assesses agnosia in a client who had a CVA. An example of this disturbance would be an inability to

recognize eating utensils. Agnosia is a disturbance in the ability to recognize familiar objects through the senses. The most common types are visual and auditory. A client with visual agnosia may examine objects curiously but be unable to determine their function.

When the spouse of a client who has had a CVA as a result of a cerebral hemorrhage asks the nurse about the client's chances for recovery, the nurse should base a reply on knowledge that with this type of CVA

recovery is slow and less complete. Hemorrhagic strokes usually produce extensive residual function loss and have the slowest recovery of all types of stroke.

When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the

right pupil does not react to light. A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of

risk for injury related to denial of deficits and impulsiveness. : Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability

During the nursing history, a patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about

rotary chair testing. The patient's clinical manifestations of dizziness and nausea suggest a disorder of the labyrinth, which controls balance and contains three semicircular canals and the vestibule. Rotary chair testing is used to test vestibular function

The nurse is concerned about a client's slowly healing corneal ulcer because such an injury can lead to

secondary glaucoma Slowly healing corneal injuries may lead to secondary glaucoma.

A client is being worked up for a possible brain tumor. An important intervention the nurse would include in the nursing care plan specific to this client is

seizure precautions.

The nurse assessing a client with an inner ear disorder would be aware that the presenting clinical manifestation will be

sensorineural hearing loss.

The nurse would consider that discharge teaching for a client after cataract surgery was not effective when the client states "I will

sleep on the side they operated on." The postsurgical cataract client should wear eye shields, avoid lifting more than 5 pounds until cleared by the ophthalmologist, and should only experience mild pain, for which acetaminophen (Tylenol) should be effective. These clients should avoid sleeping on the operated side.

To evaluate a client's balance using Romberg's test, the nurse would

stand the client with feet together, eyes closed, and arms to the side. The inner ear is assessed for balance by performing Romberg's test.

A critically injured patient can be aroused only by vigorous and continuous external stimuli. The patient's level of consciousness is considered

stuporous. The patient is stuporous when arousal is possible only in response to vigorous and continuous external stimuli

The ability to access CSF by a lumbar puncture is attributable to the flow of CSF in the

subarachnoid space.

The emergency department nurse should position the client with cranial injuries

supine with head of bed elevated 30 degrees Place the client with cranial injures supine with the head elevated 30 degrees unless contraindicated (e.g., some spinal injuries, some aneurysms).

The nurse points out the important difference between metabolically induced coma and structurally induced coma is that metabolically induced coma results in

symmetrical motor manifestations. Coma caused by a metabolic disorder more often is manifested as the presence of bilateral or symmetrical findings because the disorder affects the entire brain rather than just one section.

The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits. Which of the following should the nurse explain to the family?

symptoms of a concussion can last up to 3 months

The nursing action that would be appropriate in caring for a client who has experienced stroke because of hemorrhage is to

teach the client to avoid the Valsalva maneuver.

The region of the brain that acts as a relay station for both motor and sensory activity is the

thalamus.

As part of preoperative counseling for the client contemplating cataract surgery, the nurse would explain that postoperative follow-up is done

the day after, 1 week after, and 1 month after surgery.

A patient has bilateral senile cataracts and is scheduled for a right cataract extraction and intraocular lens implantation at an ambulatory surgical center. During the preoperative assessment of the patient, it is most important for the nurse to assess

the visual acuity of the patient's left eye. Because it can take up to several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye.

A client has a history of experiencing focal neurologic deficits, such as slurred speech and facial weakness, that last for a few hours at a time. The nurse then assesses this client for other possible manifestations of

transient ischemic attacks (TIAs). TIAs are focal neurologic deficits lasting less than 24 hours that produce manifestations of slurred speech, facial weakness, and ataxia.

A patient is recovering from surgery to clip an aneurysm. Which of the following interventions will prevent cerebral vasospasm in this patient?

triple H therapy Vasospasm decreases perfusion to brain tissue and is prevented and treated with "triple H therapy": hypervolemia, hypertension, and hemodilution

Safety precautions the nurse instructs the client with homonymous hemianopsia to use include

turning the head to scan the visual field. Clients with homonymous hemianopsia cannot see past the midline without turning the head toward that side. This can create a safety concern for the client. The client may run into objects, trip, or fall.

A nurse could appropriately assess for the doll's eye reflex in a client who is a/an

unconscious teenager who has overdosed on drugs.

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for

understanding of written and oral language. The posterior temporal lobe integrates the visual and auditory input for language comprehension

The nurse caring for a client receiving phenytoin (Dilantin) should assess for

unsteady gait, slurred speech, and blurred vision. Serious adverse outcomes of antiseizure medications are unsteady gait, slurred speech, extreme fatigue, blurred vision, or feelings of suicide.

A patient is seen in the ophthalmology clinic and diagnosed with recurrent staphylococcal and seborrheic blepharitis. The nurse will plan to teach the patient about

using baby shampoo to clean the lids. Baby shampoo is used to soften and remove crusts associated with blepharitis

Transcranial Doppler studies are used in the patient following rupture of a cerebral aneurysm to assess for

vasospasm

The critical care nurse explains to the family of a client who is to receive nimodipine following hemorrhagic stroke that the purpose of this drug is to treat

vasospasm. Nimodipine, a calcium-channel blocker, is used to treat vasospasm secondary to subarachnoid hemorrhage.

The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will anticipate that the patient may have

visual deficits. Visual disturbances are expected with posterior cerebral artery occlusion

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse will evaluate the patient for improvement in

visual field. POAG develops slowly and without symptoms except for a gradual loss of visual field. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision

To assess motor response, the nurse performing a neurologic assessment on a client in a coma would ask the client to

wiggle the toes. Motor responses are assessed by asking the client to follow specific commands, such as "wiggle your toes." Do not ask the client to squeeze your hand because grasp is a reflexive response that occurs in clients with head injury.

Neurologic testing of the patient by the nurse indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Based on these findings, the nurse plans to

withhold oral fluid or foods. The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration.

A patient who has heart failure and has been receiving large doses of IV furosemide (Lasix) tells the nurse, "I cannot hear very well. My ears are ringing." The most appropriate action by the nurse is to

withhold the ordered dose of furosemide and notify the health care provider. Because ototoxicity associated with use of furosemide can lead to deafness and tinnitus, the most appropriate action at this time is to hold the furosemide until checking with the health care provider