Restorative Neuro
What food should be eliminated from the diet of a patient with Parkinson's disease taking an MAOI inhibitor?
High Tyramine foods- cheddar cheese, cured meats, and smoked cheeses/meats
What are the signs and symptoms of Autonomic dysreflexia (AD)?
Hypertension (HTN), Flushed face, diaphoresis (sweating), and nasal congestion.
A nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected?
Hypothalamus
A nurse is providing discharge teaching to a client who is postop following cataract surgery and has an intraocular lens implant. What statement by the client indicates an understanding of the instructions
I will avoid bending over
Cranial nerve assessment: I-V
I-> it is the Olfactory nerve, is sensory for smell II-> it is the Optic nerve, is sensory for central and peripheral vision III-> it is the Oculomotor nerve, control eye movements and support sensory functioning IV-> it is the Trochlear nerve, is motor for eye movement via superior oblique muscles V-> it is the Trigeminal nerve, is sensory for perception from skin of face and scalp and mucous membranes of mouth and nose.
A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?
Impulsive behavior
A nurse is assessing a client who has increased ICP and has received IV mannitol. Which finding indicates therapeutic effect of the medication?
Increased urine output
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?
Intention tremors
A physician orders a patient to take Benztropine (Cogentin). The patient has never taken this medication before and is due to take the first dose at 1000. What statement by the patient requires you to hold the dose and notify the physician?
"I forgot to tell the doctor I take eye drops for my glaucoma."
A nurse is caring for a client who has encephalitis due to West Nile virus. Which actions should the nurse take?
-Monitor VS every 2 hr -Asses neurological status every 4 hr -Keep the client's room darkened
Signs/symptoms of increased ICP
-Restlessness -Irritability -Agitation -Altered level of consciousness (LOC) -Headaches -Sudden vomiting without nausea -All from cerebral hypoxia (low oxygen)
A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). What information should the nurse include in the teaching? (select all)
-driving can be dangerous due to the loss of peripheral vision -laser surgery can help reestablish the flow of aqueous fluid
A nurse is reinforcing teaching with a client who is preoperative for cataract surgery. The nurse should include in the teaching that which of the following is an adverse effect of cataract surgery?
Intraocular hemorrhage
How much time should you wait between administering multiple sets of Glaucoma eye drops?
5 minutes
A nurse is providing teaching to a class about transient ischemic attacks. Which information should the nurse include in the teaching?
A TIA can precede an ischemic stroke
A nurse is caring for a client who has sustained a high thoracic spinal cord injury following a diving accident. The nurse suspects that the client may be experiencing the complication of autonomic dysreflexia when the client exhibits:
A severe headache
What is the priority nursing action for a patient experiencing a corneal reflex?
Keep eyes lubricated with lubricating eye drops. (Corneal reflex=can't blink)
A 7-year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure?
Absence
A patient has bacterial meningitis, what is the nurse's primary intervention?
Administer antibiotics
A nurse is preparing a clienet for an electroencephalogram (EEG). When the client asks the nurse what this test does, what response should the nurse provide?
An EEG records the electrical activity of your brain cells.
How would a nurse prevent foot drop in a patient post stroke?
Apply a protective boot
A nurse is talking to a client's spouse about degenerative complications associated with Parkinson's disease. The highest priority topic for the nurse to talk to the spouse about is the risk for:
Aspiration
A nurse in the emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurse's priority?
Assist with Tensilon test.
What muscle relaxant would you expect to be ordered for a patient with MS?
Baclofen
Parkinson's Stage II
Bilateral limb involvement occurs, making walking and balance difficult. Masklike face; slow, shuffling gait
A nurse is triaging clients during a mass casualty event. Which labels should the nurse assign to a client who has a head injury with fixed, dilated pupils?
Black tag
A nurse is preparing an older adult client who had a TIA for discharge. The nurse should teach the client to monitor which of the following parameters at home?
Blood Pressure
A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?
Brudzinski sign
How does an osmotic diuretic work for a patient with increased intracranial pressure (ICP)?
By reducing edema in the brain
"Halo sign" test
CSF leakage from the nose and ears can indicate a basilar skull fracture. Test for the "halo sign," clear or yellow-tinted ring surrounding a drop of blood when bloody drainage is placed on a piece of gauze.
Manifestations of right-sided stroke
Class- Left sided weakness, visual disturbances, poor impulse control, poor judgment, confabulation (make-up stories they don't recall correctly from past)
Parkinson's Stage V
Client unable to stand or walk, is dependent for all care, and might exhibit dementia
A nurse is caring for a client who has Meniere's disease. The nurse should identify that Meniere's disease affects which structure of the ear?
Cochlea
What cranial nerve is responsible for the pupillary reaction to light?
Cranial nerve #3
A nurse is caring for a client who has expressive aphasia following a stroke. Which lobe of the brain was affected by the stroke?
Frontal
The patient has an L-4 spinal cord injury with Autonomic dysreflexia (AD), what are 3 potential causes?
Full bladder, pain, bowel impaction, restricted clothing, sudden change in position. (Think any noxious stimuli below level of injury)
Which nursing intervention is most appropriate when caring for patients with dementia?
Give simple directions, focusing on one thing at a time.
GLASGOW COMA SCALE
HIGHEST score 15, it is a scale used as a standard rapid neurologic assessment tool The lower the score, the lower the patient's neurologic function 3= no brain activity 15= highest score
A nurse is preparing to test the function of cranial nerve X. Which assessment procedure should the nurse use?
Have the client open his mouth and say "Aah"
What is the type of stroke that causes an acute onset of symptoms including a severe headache and loss of consciousness?
Hemorrhagic stroke
A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. What finding should the nurse expect?
Difficulty with speech
Dilantin-nursing considerations, administration
Dilantin (Phenytoin) [Class of antiepileptic medications, Hydrantoins] Side effects: *STOP MED IF RASK APPEARS
When a nurse is administering Dilantin IV push, how long should she take to instill the medication?
Dilantin should be given over 1 minute
A nurse is caring for a client who experienced a traumatic brain injury. What finding indicates increased ICP?
Dilated pupils
A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). The nurse should know that which of the following client findings supports this suspicion?
Diplopia.
What should a nurse's first action be prior to administering eye ointment?
Discard the first bead of ointment
A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement?
Dysphagia
A nurse is reviewing a laboratory result of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. The nurse should recognize which of the following findings is consistent with this diagnosis?
Elevated protein
Primary s/s of Parkinson's
Masked face, bradykinesia, oily skin
Clonic seizure
lasts several minutes. Muscles contract and relax,
Retinal detachment-treatment of/teaching points
surgical repair called scleral buckling is needed to place retina in contact with structures; preoperative the nurse needs to provide information and support to patient, instruct patient to restrict activity and head movement, an eye patch is placed over affected eye
A nurse is assessing a client who has a closed head injury and has received mannitol for manifestations of increased intracranial pressure. What findings should indicate to the nurse that the med is having a therapeutic effect?
the client's serum osmolarity is 310 mOsm/L
Primary open-angle glaucoma (POAG)
this is more common form and refers to the angle between the iris and sclera, -Expected findings are headache, mild eye pain, loss of peripheral vision, decreased accommodation, halos seen around lights, and elevated IOP
A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to adminster?
tissue plasminogen activator
A nurse is caring for a client who was admitted for status epilepticus and is on seizure precautions. Which of the following actions should the nurse plan to take?
Establish IV access
A client has been diagnosed with acute angle closure glaucoma. The nurse should expect the client to report?
Eye pain and blurred vision
What pain scale would a nurse use for a 8 month old infant?
FLACC
Which pain scale would be appropriate for a 6 month old infant?
FLACC
A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse expect?
Flashes of bright light
If a patient is on an MAOI what foods would be contraindicated?
Foods high in Tyramine (smoked, cheeses, salty foods)
A nurse is caring for a client who has just had an evacuation of a subdural hematoma following a head injury. Which of the following is the nurse's highest priority assessment?
Respiratory status
A nurse is assessing a client who has a possible head injury following a motor-vehicle crash. The nurse should recognize that which of the following findings indicates increasing intracranial pressure?
Restlessness
What should be included in patient teaching for a patient post retina repair
Restrict head and eye movement, wear an eye patch, use eye drops as directed.
Nursing care of pt with Alzheimer's-what to include in care plan
- Provide a safe environment - Encourage family to participate in an AD support group - Provide cognitive stimulation
Dysphagia-nursing considerations/interventions
Risk of aspiration is great
In which of the following positions should a nurse place a client following a craniotomy for evacuation of a subdural hematoma of the frontal lobe?
Semi-fowlers (head midline and the HOB elevated 30, allowing blood flow to the brain while allowing venous drainage, ↓ risk of IOP)
Myoclonic Seizure
brief jerking or stiffening of the extremities, which can be symmetrical or asymmetrical. Lasts for several seconds
A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level CS. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first?
Elevate the head of the client's bed.
A 65-yr-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is
c. promoting physical exercise and a well-balanced diet.
A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take?
Ensure that the client lies flat for up to 12 hr (prevent cerebrospinal fluid leakage from the puncture site, which can cause a headache)
A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse?
Severe headache
What are some side effects of Donepezil?
Syncope, bradycardia, drowsiness, and diarrhea
Parkinson's Stage IV
Tremors can decrease but akinesia and rigidity make day-to-day tasks difficult
List 3 manifestations of Parkinson's disease
Tremors, bradykinesia, drooling, orthostatic hypotension, oily skin`
Parkinson's Stage I
Unilateral shaking or tremor of one limb
What should a nurse do with the eye ointment prior to administering it?
Waste the 1st bead of ointment
A nurse is providing teaching regarding a new prescription for carbidopa-levodopa for a client who has Parkinson's disease. Which of the following client statements indicates an understanding of the teaching?
"I should expect my urine to be a darker color."
A nurse is teaching a client who has Parkinsons disease and is prescribed carbidopa-levodopa. Which of the following statements indicates an understanding of the teaching?
"I should expect that this medication can cause me to be drowsy."
A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicated that the client understand the teaching?
"I will avoid going to the store when it is crowded."
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?
"I will brush my teeth after every meal."
A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching?
"The drugs used to treat Alzheimer's disease can help delay cognitive changes.
A nurse is reinforcing discharge teaching with a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching?
"You should expect to see flashing lights in front of the affected eye after the procedure."
What is the priority intervention for a child with bacterial meningitis?
- Antibiotics- the priority is to treat the infection
Types of seizures
- Generalized - Partial or focal/local seizure - Unclassified or Idiopathic
SCI- know associated levels of injury/what body functions would be affected
- Hyperflexion: sudden and forceful movement of the head forward. - Hyperextension: head going backward - Axial loading or vertical compression: diving into a pool hit your head, fall and land on your feet, blow on top of your head. - Excessive rotation: Breaking their neck, turning head beyond normal ranges - Penetrating trauma: knife wounds, gunshots, sticks,
Brudzinski sign- if you press a patient's shoulders down while they flex their neck.
- If they flex knees and hips, it is considered a positive sign. Reason is the neck flexion causes spinal cord to press on meninges causing the patient pain. They will involuntarily flex knees and hips to reduce the pain.
Meinere's disease-nursing care of
- Teach patients how to modify their diet accordingly - Teach to avoid activities that place them at risk experiencing vertigo, such as standing on chairs or ladders. - Patients with sudden drop attacks, should not drive, may have their drivers license suspended. - Teach patients to move head slowly to prevent worsening of vertigo. Institute and teach fall precautions
Post op cataract surgery pt teaching
- Wear sunglasses while outside or in brightly lit areas. - Report manifestation of infection, yellow or green drainage. - Avoid activities that increase IOP (intraocular pressure) -- Bending over at the waist, sneezing, blowing nose, coughing, straining, head hyper-flexion, restrictive clothing (right shirt collars), sexual intercourse.
A nurse is educating a client who was just diagnosed with open angle glaucoma about the condition. Which of the following information should the nurse include in the teaching? (Select all that apply)
-Do not take cold medications that contain pseudoephedrine. -Expect impaired night vision. -Driving may be dangerous due to loss of peripheral vision. -Laser surgery can help reestablish the flow of aqueous humor.
What is the priority nursing action for a 3-day post-op patient with purulent drainage?
Notify surgeon (sign of infection contact provider)
A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. Which additional findings would the nurse expect?
Nystagmus or confusion
A client with a seizure disorder is being discharged. The client's family has many questions about what to do if the client has a seizure while at home. The nurse tells the family members that the first action to take in the events of a seizure is to:
Ease the client to the floor if standing or seated.
A nurse is admitting a client who has bacterial meningitis. The nurse notes during the physical examination that the client cannot extend his leg when his hip is flexed so that his thigh rests on his abdomen. The nurse should document this as which of the following?
Kernig's sign
A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?
Maintain a PaCO2 of approximately 35 mm Hg.
Autonomic Dysreflexia-assessment, priority nursing interventions, treatment
Monitor the bladder, bowels and skin- remove and prevent the triggering stimuli Place the patient in a sitting position -> this helps lower BP - A physical exam and imaging studies need to be done With autonomic dysreflexia- the HR decreases but the BP is increased - ISSUES that can happen are distended bladder or recutum
A nurse responds to a call from an assistive personnel that a client just had a seizure and is unconscious. which of the following assessments is the nurse's priority
check airway patency
A nurse is trying to assess the function of the trigeminal nerve (CN V). Which of the following items should the nurse gather for the test?
cotton wisps
Unclassified or Idiopathic
do not fit into any category, half of all seizure activity and no known reason for occurrence
A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?
clear drainage from nose
What are the symptoms of a ruptured ear drum in a child?
Pain relief and ear drainage
A nurse is caring for a client who is post-op following a craniotomy to evacuate a subdural hematoma. The nurse notes the client's UO is greater each hour than the previous hour; from 1800 to 1900 the UO was 200 mL, from 1900 to 2000 the UO was 400 mL, and from 2000 to 2100 the UO was 600 mL. The nurse informs the surgeon and anticipates that the lab value that will be prescribed at this time is:
Specific gravity
Partial or focal/local seizure
They are... - Complex partial seizure - Simple Partial seizure
Halo device-purpose, patient/family teaching
This is to immobilize the cervical spine and is worn for 6-12 weeks -may alter balance, be careful when leaning forward - wear loose clothing - bath in bathtub or sponge bath - do not drive
Subdural hematoma-nursing care, interventions
- Assessment findings- classically begin with headaches, drowsiness, restlessness or agitation, slowed cognition, and confusion. - Pupils also dilate and there is a change in respiratory pattern
Parkinson's Stage III
Physical movements slow down significantly, affecting walking more. Postural instability.
A nurse is caring for a client who has a brainstem injury. Which physiological function should the nurse monitor?
Respiratory Effort
A patient is 4 hours post op for a subdural hematoma. What is the nurse's priority?
Respiratory Status
A nurse is providing teaching to a client who has a history of tonic-clinic seizures and is scheduled for a standard electroencephalogram (EEG). Which instruction should the nurse include?
Thoroughly shampoo her hair prior to the EEG and avoid styling products
Signs/symptoms of tympanic rupture
Tinnitus, pain in middle ear, hearing loss, loss of balance, fluid draining from ears.
Atonic or akinetic Seizure
few seconds in which muscle tone is lost which frequently results in falling, followed by a period of confusion,
Generalized seizures
involve both cerebral hemispheres, can begin with an aura (alteration in vision, smell, hearing, or emotional feeling) They are... - Tonic-clonic - Tonic Seizure - Clonic seizure - Myoclonic Seizure - Atonic or akinetic Seizure
A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease. What info should the nurse include in the teaching?
limit choices offered to the client
A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority?
The client's ability to clear oral secretions
Medications expected with moderate to severe Alzheimer's disease
- Memantine - Donepezil - Cholinesterase Donepezil is meant to slow the cognitive decline
Seizure care-child, adult
- Protect the client from injury, move furniture away, hold head in lap if on the floor. - Position the client to provide a patent airway. - Turn the client to their side to reduce the risk of aspiration. - Loosen restrictive clothing
SCI drugs/interventions
- Proton pump inhibitors risk for ulcer in stomach (pantoprazole) - Skeletal muscle relaxants (tizanidine) causes drowsiness - Baclofen- right into spinal cord, pump into CSF - Surgery (fusions)- remove bone fragments- within 24 hr to prevent secondary injury (hematoma, bullet, knife wound) - ABC- rehab ASAP- may need trach/vent
A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?
monitor pulse oximetry findings
MS-nursing care of/family teaching
monitor visual activity, speech patterns such as fatigue with talking, swallowing, activity tolerance, and skin integrity;
A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include?
move your head slowly to decrease veritgo
Primary angle-closure glaucoma-
OP rises suddenly and the angle between the iris and sclera is closed suddenly which causes a corresponding increased in IOP, it requires immediate treatment; -Expected findings are rapid onset of elevated IOP (30 or higher), decreased or blurred vision, colored halos seen around lights, pupils nonreactive to light, severe pain and nausea, and photophobia
A nurse in an emergency room is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer?
Osmotic diuretics via IV bolus
A nurse is teaching an assistive personnel (AP) about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?
Place an abductor pillow between the client's legs when turning the client
Glaucoma-types, difference between
Primary open-angle glaucoma (POAG) Primary angle-closure glaucoma-
A client has undergone surgical repair via scleral buckling of a detached retina of the left eye with an injection of a gas bubble. The nurse should anticipate that the surgeon will prescribe the client to assume which postoperative position?
Prone position with operated eye up
Seizure care-child, adult
Protect the client from injury, move furniture away, hold head in lap if on the floor. Position the client to provide a patent airway. Turn the client to their side to reduce the risk of aspiration. Loosen restrictive clothing
What is the priority action taken when a patient has a seizure?
Protect them from injury
What is the intervention used to decrease risk for foot drop in a patient with right sided paralysis?
Protective boot to right lower leg
A nurse is caring for a client who has an impairment of cranial nerve II. Which action should the nurse perform to promote the client's safety?
Provide an obstacle-free path for ambulation
A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take?
Redirect the client to a different activity with a small group of people.
A nurse is providing discharge teaching to a client who has had a transient ischemic attack (TIA). What instructions should the nurse include?
Reduce dietary sodium
The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority?
Respiratory assessment
What is the priority nursing assessment for a patient 4-hour post-op subdural hematoma evacuation?
Respiratory assessment
What is the first action of the nurse who suspects a patient is having autonomic dysreflexia
Sit them up- High fowlers
A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?
Stroke the client's inner thigh.
A nurse is preparing to admit a client with myasthenia gravis who has been having increasingly frequent episodes of myasthenic crises. Because of the client's history, which of the following equipment should the nurse ask the AP to place at the client's bedside?
Suction machine & suction catheters
Autonomic Dysreflexia
Sudden, significant rise in systolic and diastolic b/p accompanied by bradycardia. - Risk factor- distended bladder, UTI (something irritating the nervous system), bowel distention/impaction, hemorrhoids, vascular stimulation, pain, tight clothing in thorax/abdomen, large temp flux. - immediate intervention SIT THEM UP
Tonic Seizure
Suddenly lose consciousness, increased muscle tone, autonomic manifestations (arrhythmia, apnea, vomiting, incontinence, salvation) - Usually last less than 30 seconds (can be several minutes)
A nurse is assessing a client who has a new diagnosis of mastoiditis. Which manifestation should the nurse expect?
Swelling behind the affected ear
A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the client's medication teaching plan?
Take medications at a consistent time each day to maintain therapeutic blood levels.
A nurse is caring for a client who has receptive aphasia. Which communication problem should the nurse expect when assessing the client?
The client is unable to understand words or sentences she hears
Tx of post-lumbar puncture headache
The client should remain lying for several hours to ensure that the site clots and to decrease the risk of a post-lumbar puncture headache, caused by CSF leakage.
A nurse is collecting data from a client who has a closed head injury and is receiving mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates to the nurse that the medication is having a therapeutic effect?
The client's urine output is 250 mL/hr.
The neurologist is conducting a Tensilon test (Edrophonium) at the bedside of a patient who is experiencing unexplained muscle weakness, double vision, difficulty breathing, and ptosis. Which findings after the administration of Edrophonium would represent the patient has myasthenia gravis?
The patient experiences improved muscle strength
A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?
The purpose of this device is to immobilize the cervical spine
Which characteristic will the nurse associate with a focal seizure?
The seizure involved lip smacking and repetitive movements.
Guillain-Barre Syndrome: signs/symptoms, nursing interventions/assessment
Tingling and weakness to paralysis of the legs or complete quadriplegia, respiratory insufficiency, and ANS instability. - Absent deep-tendon reflex, muscle weakness (inability to lift the head), respiratory failure (weak cough, dyspnea, hypoxia) - Nursing considerations- airway management (suction, intubation and oxygen at the bedside, possible mechanical ventilation, aspiration precautions)
A bolus of mannitol (Osmitrol) is ordered for a client with a closed-head injury showing manifestations of increasing intracranial pressure. Prior to administration, assessment shows: UO 40 mL/hr, apical HR 88/min, and the pupils equal and reactive. The client is sleepy but easily aroused. After administering mannitol to the client, which of the following should indicate to the nurse that the medication is having the desired effect?
UO is 100 mL/hr (osmotic diuretic used to ↑ UO and ↓ cerebral edema)
A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply)
Violent headache Slurred speech Projectile vomiting Rapid loss of consciousness
A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which finding is an early manifestation of ALS?
Weakness of the distal extremities
What teaching should be including for discharging a post-op cataract surgery patient?
Wear dark colored glasses outside or well-lit areas, eye itching and creamy white eye drainage are to be expected, avoid taking NSAID's.4
What is an expected finding in a patient with cataracts?
Whitening on the eye lens, decreased colored vision, and cloudiness in eye
A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?
Widened pulse pressure
Tensilon test
a tensilon test using the drug Tensilon to help diagnose certain neural diseases, like myasthenia gravis.
A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. What statements by the client indicates an understanding of the teaching?
an aura is a sensory warning that a seizure is imminent
Complex partial seizure
automatisms (client unaware: lip smacking, picking @ clothes), can cause loss of consciousness or blackout for several minutes, amnesia can occur immediately prior to and after the seizure
A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. What instructions should the nurse include in the teaching?
avoid sudden movements
Tonic-clonic seizure
begins with few seconds of tonic (stiffening of muscles) and loss of consciousness. Follows with 1-2 min clonic (rhythmic jerking of the extremities) - Breathing can stop during tonic and irregular during clonic phase an be accompanied with cyanosis, Biting cheek or tongue w/clonic, possible incontinence - Postictal phase- period of confusion and sleepiness follows the seizure
A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?
check capillary refill at least every 4 hr
Simple Partial seizure
consciousness maintained, unusual sensations, sense of deja vu, autonomic abnormalities (changes in heart rate & abnormal flushing), unilateral abnormal extremity movements, pain, or offensive smell
A nurse is providing teaching to the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that what manifestations is the priority?
dysphagia
A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. What supplies should the nurse place at the client's bedside?
oral-nasal suction equipment
6-month old post op mirongotomy
pain scale = FLACC (6 mo - 2 yr)
A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. after checking the client's vital signs, which of the following actions should the nurse perform next a. administer n
place the client in a high-fowler's position.
A nurse is caring for a client who has an impairment of Cranial Nerve II. Which of the following actions should the nurse perform to promote the client's safety?
provide an obstacle free path for ambulation
A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions?
remind the client to look consciously at both sides of their meal tray
A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify what findings as a manifestation of autonomic dysreflexia?
report of a headache
A nurse a caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?
request a prescription for gabapentin for the client.
A nurse is assessing a client who report vision loss. The client describes the loss as beginning with a flash of light following a curtain across the field of vision. the nurse should identify that these manifestations indicate which of the following eye disorder
retinal detachment-no pain
Nuchal rigidity (stiff neck)-priority nursing interventions
s/s meningitis Isolate as soon as meningitis is suspected. Initiate droplet precautions
A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?
severe eye pain
A nurse is assessing a client who has Guillain-Barre syndrome. What finding should the nurse expect?
weakness in the lower extremities
A nurse is providing discharge teaching to a client who is postop following scleral buckling to repair a detached retina. What instructions should the nurse include in the teaching?
you should avoid reading for 1 week
