Prepu Neuro
Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia? a) Monitoring the patency of an indwelling urinary catheter b) Assessing laboratory test results as ordered c) Placing the client in the Trendelenburg's position d) Administering zolpidem tartrate
A
The nurse is caring for a client with a diagnosis of cerebrovascular accident (CVA) with left-sided hemiparesis. What would be important nursing measures in the acute phase of care? Select all that apply. a) Turn and position every 2 hours. b) Perform passive range of motion on the affected side. c) Support the affected side with pillows. d) Perform active range of motion on both sides. e) Perform passive range of motion on both sides.
A,B,C
A client has short-term memory loss. To help the client cope with memory loss, the nurse should: a) tell the client in the morning what activities will be expected to be performed that day. b) place a single-date calendar where the client can view it. c) ask the client to try harder to remember things. d) instruct family members to ignore the behavior.
B
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a) Kernig's sign. b) a positive sweat chloride test. c) Brudzinski's sign. d) a positive edrophonium test.
D
An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element? a) protein b) sodium c) fluids d) potassium
B
The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should: a) assist the UAP with getting the client back in bed. b) have the UAP keep a steady pull on the client to promote forward ambulation. c) explain how to overcome a freezing gait by telling the client to march in place. d) give the client a muscle relaxant.
C
The nurse receives a physician's order to administer 1,000 mL of intravenous (IV) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.
31
nurse is assessing a client with a brain injury. What is a client's cerebral perfusion pressure (CPP) when the blood pressure (BP) is 90/50 mm Hg and the intracranial pressure (ICP) is 21? Round to the nearest whole number.
42
A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? a) "Avoid stimulants and alcohol for 24 to 48 hours before the test." b) "Don't shampoo your hair for 24 hours before the test." c) "Don't eat anything for 12 hours before the test." d) "Avoid thinking about personal matters for 12 hours before the test."
A
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? a) "The client is unaware of his left side. You should approach him on the right side." b) "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." c) "This condition is temporary." d) "The client is unaware of his left side. You need to encourage him to interact from this side."
A
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? a) Determine whether the client is allergic to iodine, contrast dyes, or shellfish. b) Immobilize the neck before the client is moved onto a stretcher. c) Administer a sedative as ordered. d) Place a cap over the client's head.
A
A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first? a) Advise the client to discard the drug because it may have undergone chemical changes or become contaminated. b) Advise the client to keep the container closed tightly and protected from light. c) Watch the client or a family member administer the drug to determine possible contamination sources. d) Advise the client to obtain a fresh container of pilocarpine solution to avoid omitting ordered doses.
A
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? a) Administer stool softeners. b) Position the client with the head turned toward the side of the brain tumor. c) Provide sensory stimulation. d) Encourage coughing and deep breathing.
A
A parent of a child with a moderate head injury asks the nurse, "How will you know if my child is getting worse?" The nurse should tell the parents that best indicator of the child's brain function is: a) level of consciousness. b) reactions of the pupils. c) the vital signs. d) motor strength.
A
After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs, and calls the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurate? a) "The movements occur from muscle reflexes that cannot be initiated or controlled by the brain." b) "These movements indicate that the damaged nerves are healing." c) "This is a good sign. Keep trying to move all the affected muscles." d) "The return of movement means that eventually you should be able to walk again."
A
Because of symptoms experienced after a cerebrovascular accident (CVA), the nurse discovers that a client needs assistance using utensils while eating. What would the nurse do to support this activity of care? a) Encourage participation in the feeding process to the best of the client's abilities. b) Feed another patient and wait in the dining room until the client can accomplish feeding. c) Request that the client's food be pureed by dietary staff. d) Have the family feed the client at every meal to reduce staffing limitations.
A
The client with retinal detachment in the right eye is extremely apprehensive and tells the nurse, "I am afraid of going blind. It would be so hard to live that way." What factor should the nurse consider before responding to this statement? a) Optimism is justified because surgical treatment has a 90% to 95% success rate. b) More and more services are available to help newly blind people adapt to daily living. c) Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable. d) The surgery will only delay blindness in the right eye, but vision is preserved in the left eye.
A
The nurse is assessing a client with a head injury. On admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in neurologic status of the client suggest to the nurse? a) Increased intracranial pressure b) Decreased intracranial pressure c) This is a normal response after a head injury, and the pupils will be expected to return to normal. d) The test was not performed accurately; there was too much light in the examination room.
A
The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which of the following nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions? a) Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. b) Eat foods containing vitamins C, D, and E, and drink at least 2 L of fluid a day. c) Drink a large amount of fluids, especially milk products, and eat a diet that includes multiple sources of vitamin D. d) Eat foods and ingest fluids that will cause the urine to be less acidic.
A
Which of the following clients requires increased sensory stimulation to prevent sensory deprivation? a) A 65-year-old client who has employment-induced presbycusis and advanced glaucoma b) A 24-year-old client who has been admitted with an anxiety disorder and appears very agitated c) An 84-year-old client who has hemiparesis and ambulates with a walker d) A 60-year-old client who is blind, reads books through use of Braille, listens to the radio, and regularly takes walks around the unit
A
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? a) Migraine headache b) Trigeminal neuralgia c) Angina pectoris d) Bell's palsy
B
A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an I.V. injection of a medication. What is the medication the nurse tells the client he'll receive during this test? a) Cyclosporine b) Edrophonium c) Azathioprine d) Immunoglobulin G
B
A client who is prescribed by the health care provider (HCP) to take aspirin daily in order to prevent thrombus formation reports having ringing in the ears. The nurse advises the client to take which measure? a) Use acetaminophen instead. b) Contact the HCP. c) Increase fluid intake. d) Stop taking the aspirin.
B
A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client? a) "Can you tell me your name and where you live?" b) "You are in the hosipital. You were in an accident and unconscious." c) "I will get your family." d) "I will bet you are a little confused right now."
B
A nurse is assessing a client with meningitis. The nurse places the client in a supine position and flexes the client's leg at the hip and knee. The nurse notes resistance when straightening the knee and the client reports pain. The nurse should document what neurologic sign as positive? a) Lichtheim's sign b) Kernig's sign c) Babinski's reflex d) Brudzinski's sign
B
Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which body system? a) cardiac b) gastrointestinal c) pulmonary d) renal
B
The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position? a) side-lying on the affected side b) semi-Folwer's c) side-lying on the unaffected side d) supine
B
The nurse enters the client's room as the client, who is sitting in a chair, begins to have a seizure. The nurse should first: a) restrain the client's body movements. b) ease the client to the floor. c) insert an airway into the client's mouth. d) lift the client onto his bed.
B
The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. The nurse should: a) dispose of the residual and continue with the feeding. b) readminister the residual to the client and continue with the feeding. c) withhold the tube feeding and notify the health care provider (HCP). d) delay feeding the client for 1 hour and then recheck the residual.
B
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: a) fill out the menu for the client. b) stay with the client and encourage him to eat. c) give the client privacy during meals. d) help the client fill out his menu.
B
What should the nurse do first>/b> when a client with a head injury begins to have clear drainage from the nose? a) Administer an antihistamine for postnasal drip. b) Collect the drainage. c) Compress the nares. d) Tilt the head back.
B
When assessing the client with Parkinson's disease, the nurse should observe the client for: a) aphasia. b) a stiff, masklike facial expression. c) dry mouth. d) an exaggerated sense of euphoria.
B
Which is an initial sign of Parkinson's disease? a) akinesia b) tremor c) bradykinesia d) rigidity
B
Which statement indicates the client understands the expected course of Ménière's disease? a) "Continued medication therapy will cure the disease." b) "Control of the episodes is usually possible, but a cure is not yet available." c) "The disease process will gradually extend to the eyes." d) "Bilateral deafness is an inevitable outcome of the disease."
B
A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment? a) To serve as a stopgap measure until help arrives b) To hasten formation of scar tissue c) To prevent vision loss d) To eliminate the need for medical care
C
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: a) thinking and reasoning. b) visual acuity. c) body temperature control. d) balance and equilibrium.
C
A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which of the following? a) Paralytic ileus b) Renal failure c) Meningitis d) Pneumonia
C
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? a) Dressing or grooming self-care deficit b) Disturbed sensory perception (tactile) c) Ineffective breathing pattern d) Impaired physical mobility
C
A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? a) Parietal b) Temporal c) Occipital d) Frontal
C
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? a) Pupillary asymmetry b) Irregular breathing pattern c) Declining level of consciousness (LOC) d) Involuntary posturing
C
A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which area that is a potential pressure point when the client is in this position? a) sacrum b) occiput c) ankles d) heel
C
A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client? a) "I will get your family." b) "I will bet you are a little confused right now." c) "You are in the hosipital. You were in an accident and unconscious." d) "Can you tell me your name and where you live?"
C
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? a) "Depression may manifest as dementia in elderly clients." b) "Drug interactions are the most common cause of dementia in the elderly." c) "The most common cause of dementia in the elderly is Alzheimer's disease." d) "Dementia is a terrible disease of the elderly."
C
A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time he's admitted to the intensive care unit (ICU) for aggressive treatment. She's meeting with the team to develop a change strategy using indicators. Which statement by a team member indicates a need for further teaching regarding performance management? a) "We can collaborate with staff from the ED and the ICU to formulate strategies and implement change." b) "We can review ED staffing to see if shortages affect ICU admission." c) "We can discipline the ED staff for not getting the clients to the ICU fast enough." d) "We can use statistics gathered in the ED during triage to determine the average time for admission to the ICU."
C
A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed? a) Complete the assessment of the new client before attending to the client who underwent laminectomy. b) Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the physician. c) Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. d) Ask the nursing assistant to notify the physician of the low pulse oximetry level.
C
The nurse is assessing the level of consciousness for a client who just had open heart surgery. When asked, the client can give his name but is not sure about where he is or the time of day. What should the nurse do? a) Notify the surgeon. b) Encourage the client's wife to orient the client. c) Tell the client where he is and the time of day. d) Rub the client's sternum to arouse the client.
C
The nurse is instructing a client with Ménière's disease how to recognize vertigo. The nurse should tell the client to notice: a) light-headedness. b) an episode of blackout. c) a feeling that the environment is in motion. d) narrowed vision preceding fainting.
C
What assessment findings would indicate an emergency myasthenia crisis? a) Impairment of functioning of the autonomic and skeletal muscles b) Airway obstruction, profound muscle weakness, and inability to move c) Severe dyspnea, intensification of dysphagia, and dysarthria d) Paralysis of the muscles and hyperventilation
C
Which technique is appropriate when the nurse is irrigating an adult client's ear to move cerumen? a) After instilling the solution, pack the ear canal tightly with a cotton ball. b) Use sterile solution and equipment. c) Allow the irrigating solution to run down the wall of the ear canal. d) Make sure the irrigating solution is cool.
C
A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, "How does glaucoma damage my eyesight?" The nurse's reply should be based on the knowledge that COAG: a) is caused by decreased blood flow to the retina. b) results from chronic eye inflammation. c) leads to detachment of the retina. d) causes increased intraocular pressure.
D
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? a) Monitor the client's heart rhythm. b) Prepare for gastric lavage. c) Obtain a urine specimen for drug screening. d) Prepare to assist with ventilation.
D
A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent: a) common adverse reactions to corticosteroid therapy. b) incorrect ointment application. c) expected drug effects that should diminish over time. d) increased intraocular pressure (IOP).
D
A client with quadriplegia is in spinal shock. What finding should the nurse expect? a) Positive Babinski's reflex along with spastic extremities b) Hyperreflexia along with spastic extremities c) Spasticity of all four extremities d) Absence of reflexes along with flaccid extremities
D
A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when she: a) determines a client's identity from a computer chart. b) documents medications before administration. c) e-mails information about a client to a friend at home. d) documents medications after administration.
D
A nurse completing her management rotation in the intensive care unit (ICU) is working with an experienced ICU nurse. One client's work supervisor calls to "check up" on the client. The nurse offers to transfer the call to the client's family members. The experienced ICU nurse recognizes this action as: a) passing the buck to avoid work. b) a violation of privacy laws. c) a clever way of avoiding the supervisor. d) protection of the client's privacy.
D
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? a) Prone, with the head turned to the right b) Supine, with the knees raised toward the chest c) Lateral, with right leg flexed d) Lateral recumbent, with chin resting on flexed knees
D
A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests? a) Electrocardiography, TEE, prothrombin time (PT), and International Normalized Ratio (INR) b) Transesophageal echocardiogram (TEE), troponin levels, and a complete blood count c) X-ray of the brain, bone marrow aspiration, and EEG d) EEG, blood cultures, and neuroimaging studies
D
As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability? a) "I cannot have sexual intercourse because it causes hypertension, but other sexual activity is okay." b) "I will not be able to have sexual intercourse until the urinary catheter is removed." c) "I should be able to participate in sexual activity, but I will be infertile." d) "I can participate in sexual activity but might not experience orgasm."
D
Complications associated with a tracheostomy tube include: a) pneumothorax. b) acute respiratory distress syndrome (ARDS). c) decreased cardiac output. d) damage to the laryngeal nerve.
D
Sodium polystyrene sulfonate is prescribed for a client following crush injury. The drug is effective if: a) the pulse is weak and irregular. b) the ECG is showing tall, peaked T waves. c) there is muscle weakness on physical examination. d) the serum potassium is 4.0 mEq/L (4.0 mmol/L).
D
The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? a) left Sims position b) the head elevated on two pillows c) Trendelenburg's position d) the head of the bed elevated 15 to 20 degrees
D
To assess a client's cranial nerve function, a nurse should assess: a) arm drifting. b) hand grip. c) orientation to person, time, and place. d) gag reflex.
D
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? a) encouraging the client to speak slowly b) asking the client to repeat indistinguishable words c) encouraging the client to speak distinctly d) asking the client to speak louder when tired
D
Which action is contraindicated for a client with seizure precautions? a) allowing the client to wear his or her own clothing b) encouraging the client to perform his or her own personal hygiene c) encouraging the client to be out of bed d) assessing the client's oral temperature with a glass thermometer
D
Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? a) turning b) deep breathing c) passive range-of-motion (ROM) exercises d) coughing
D
Which statement indicates that a client understands the nurse's teaching about phenytoin for the diagnosis of seizures? a) "I will only be on this type of medication for a short while." b) "This medication can help reduce my anxiety." c) "This medication may keep me awake." d) "This medication will not cure my disease."
D