unit 2 exam term 5

A nurse is assisting a team of providers in the recovery phase for a client with a neurologic deficit. A program of care will be outlined to meet immediate and long-term goals. What would the nurse anticipate seeing on the plan of care? Select all that apply.

-Client will meet with an occupational therapist to determine which adaptive devices will assist with eating and grooming. -Client will meet with a nutritionist to address nutritional deficiencies. -Client will enroll in a physical therapy program.

A client is brought to the emergency department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other conditions are considered neurologic deficits? Select all that apply

-Impaired speech -Abnormal bladder elimination -Paralysis

Which are possible long-term complications of spinal cord injury? Select all that apply

-autonomic dysreflexia -respiratory infection

A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply.

-respiratory distress -difficulty swallowing

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?

15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days

Working hard to memorize the functions of the cranial nerves is a typical part of nursing school. Not only is it important to correlate the proper nerve number and name, but including the proper function makes this task quite a challenge! Which cranial nerves are enabling you to read this question?

All options are correct. The oculomotor (III), abducens (VI) and trochlear (IV) nerves all work within the functional realm of the eyes. Don't forget the optic (II) nerve!

A client undergoes a scheduled electroencephalogram (EEG). Which of the following post-procedure activities should the nurse carry out for the client?

Allow the client to rest and shampoo the client's hair

In which of the following disease processes is the nurse most likely to care for a client in the chronic phase of a neurologic disease?

Alzheimer's disease

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask?

Are you allergic to seafood or iodine?

An 80-year-old man has been brought to the emergency department (ED) by his daughter, who states that her father has become confused and agitated over the past several days. The daughter expresses fear that her father is "getting senile" and states that this concern is what prompted her to seek care. The ED nurse and the other members of the care team should prioritize which of the following aspects of assessment?

Differentiating delirium from dementia

Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field?

Ensure a clutter-free walkway

An emergency department nurse is admitting a client brought in by the paramedics after falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client?

Goal is to stabilize the client and prevent further neurologic damage.

The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?" The nurse is most helpful to say which of the following?

Grief is a normal process. Let's discuss offering support throughout the process.

To help assess a client's cerebral function, a nurse should ask:

Have you noticed a change in your memory?" Explanation: To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status

A patient has been diagnosed with a deficiency of the major neurotransmitter acetylcholine. Based on this information, the nurse knows to assess the patient for complications associated with:

Heart rate and rhythm.

What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurologic deficit?

Help the client to the bathroom at a particular time each day.

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action?

Immediate craniotomy

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?

Sympathetic nervous system

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid.

A nursing instructor is teaching the senior nursing class about clients with neurologic disorder. The instructor tells the students that these clients are at risk of disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. What nursing intervention helps prevent plantar flexion?

Use of a footboard

The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client?

Using the incentive spirometer as prescribed

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with

body temperature control.

A high school basketball player collides with another player during a game, falls, and hits their head on the court. An MRI reveals small hemorrhages in brain tissue and edema at the injury site. The ED physician explains that the client has a cerebral ________ and further explains that the MRI indicates that the head's direct hit to the floor caused a ________ injury.

contusion; coup

A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:

is not responding to stimuli

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The brain stem consists of the midbrain, pons, and medulla oblongata. Which part of the brain contains regulatory centers for heartbeat, vasomotor activity, and breathing?

medulla oblongata

The nurse is assessing a client's level of consciousness. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of conscious should the nurse document?

somnolent

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to:

stick out the tongue and move it rapidly from side to side and in and out

A home health nurse is assisting the wheelchair-dependent, post-cerebrovascular accident client in transition from the rehabilitative center to home. Which of the following concerns would the nurse address first when assessing the client's home?

Steps to the front door

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest?

Take small meals of nutrient and calorie-dense food.

A client with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize?

Assessment of nutritional status

A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with:

dysarthria

Which medication classification is used preoperatively to decrease the risk of postoperative seizures?

Anticonvulsants

Which cerebral lobes is the largest and controls abstract thought?

Frontal

A patient has left-sided hemiplegia as the result of a brain attack (cerebrovascular accident). While being dressed, the patient states in a disgusted tone of voice, "I feel like a 2-year-old. I can't even get dressed by myself." What is the nurse's best response?

"It's hard to feel dependent on others.

An older adult man has been diagnosed with Parkinson's disease and has begun treatment with levodopa and carbidopa. When providing health education about his new medication regimen, what should the nurse teach the man?

"This medication helps significantly but the benefits tend to decrease over time."

The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply

-Anticonvulsants -Analgesics -Antibiotics

As part of a start-of-shift nursing assessment, the nurse is documenting a patient's neurological status according to the Glasgow Coma Scale (GCS). What responses will the nurse assess to determine the patient's GCS score? Select all that apply.

-Best eye opening -Best verbal response -Best motor response

The nurse is assisting in the discharge process where a female, paralyzed client is returning home with her husband and two children. Which of the following prescription classifications, used prior to hospitalization, is most important to relate to the physician when discharging?

Birth control pills

A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for:

Bleeding from the ears

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply

Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care?

Administration of thorough oral hygiene

A patient with Parkinson's disease asks the nurse what can be done to prevent problems with bowel elimination. What would be an intervention that would assist this patient with a regular stool pattern?

Adopt a diet with moderate fiber intake.

The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?

Allergic reaction to the imaging material

To alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. What health education should the nurse provide to the client before initiating this treatment?

Blood levels of the drug must be monitored.

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two illustrations of posturing shown, which demonstrates a more severe dysfunction?

Both decerebrate posturing and decorticate posturing indicate serious brain injury. Decerebrate posturing (B) involves extreme extension of the upper and lower extremities and indicates severe damage at the lower midbrain and upper pons

A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state?

Confusion

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion?

Contusion

A client being treated for a brain tumor is exhibiting signs and symptoms of cerebral edema. The nurse anticipates that the practitioner will most likely prescribe which agent?

Corticosteroid

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

Dexamethasone

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?

Declining level of consciousness (LOC)

To evaluate a client's cerebellar function, a nurse should ask:

Do you have any problems with balance?

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids

The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa for 7 years. For what common side effect should the nurse assess this client?

Dyskinesia

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?

Dyskinesia

Which activity should be avoided in clients with increased intracranial pressure (ICP)

Enemas

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication?

Falls

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

Gingival hyperplasia

The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurse's best response?

Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."

The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure?

IV diazepam

A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify?

Improved quality of life

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?

Initiate seizure precautions.

What is the function of cerebrospinal fluid (CSF)?

It cushions the brain and spinal cord.

A client with neurologic disorder is at risk for disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. Which nursing intervention facilitates the functional use of the limbs?

Keep extremities at neutral position

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?

Loosen the client's restrictive clothing

Which term describes the fibrous connective tissues that cover the brain and spinal cord?

Meninges

A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result?

Positive Romberg test, indicating a problem with equilibrium

Which of the following assessment tools should the nurse use to perform a neurologic assessment?

Mini-Mental Status Examination

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

My children are at greater risk to develop this disease.

The home care nurse is evaluating a post-cerebrovascular accident (CVA) client 1 week after returning to the home from a rehabilitation setting. Which of the following statements, made by the client, most concerns the nurse?

My spouse goes to work in the morning and leaves my lunch at my bed stand.

The nurse is providing education about meningitis to a community group of adolescents preparing for their first year at college and who plan to live in a dormitory. Which of the following would be important to include?

Obtain the meningococcal conjugated vaccine.

When a nurse is caring for a client diagnosed with neurologic deficit who has begun responding to those around him, what therapy should the nurse suggest to help strengthen muscles that are under voluntary control?

Occupational therapy

Which cranial nerve is responsible for muscles that move the eye and lids?

Oculomotor

The ED is notified that a 6 year old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy?

Preserving brain homeostasis

The nurse caring for a client in the chronic phase of a neurologic deficit knows that nursing management focuses on what?

Preventing physical and psychological complications

During the acute phase of a debilitating cerebrovascular accident, which nursing intervention is most helpful in promoting the rehabilitation of the client?

Prevention of joint contractures

A client with a neurologic deficit has been admitted to the nursing unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately?

Report the change to the physician.

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following?

Respiratory function

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Rising blood pressure and bradycardia

Which nursing technique best allows the client with slight expressive aphasia to communicate his feelings about using adaptive equipment in public?

Sit beside client and patiently assist in interpreting communication

A client newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the client to implement?

Sleep on a firm mattress.

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?

Suicidal ideations

A nurse is caring for a client with recent history of migraines. What aspect of this client's current status may rule out the safe use of triptans?

The client has angina.

A client for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the client?

The test may result in dizziness or lightheadedness

The nurse is talking with a newly paralyzed client and his wife. The wife is trying to raise the client's spirits and begins talking about the possibility of them having a baby. When the wife is alone, which instruction is essential?

There is a reduced ability for your husband to be able to father children

A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:

Tremors and muscle rigidity

Which cranial nerve is responsible for facial sensation and corneal reflex?

Trigeminal

A client with increased intracranial pressure is receiving mannitol via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment?

Urine output is increased.

A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way?

Weakness starting in the muscles supplied by the cranial nerves

The nurse is instructing the client on how to perform Credé's maneuver. In which situation is this maneuver helpful?

When a client is attempting to empty the bladder

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?

X

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?

XII

Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area?

computed tomography (CT)

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move the client to a flat surface and turn him on his side.

A neurologic deficit is best defined as a deficit of the:

central and peripheral nervous systems with decreased, impaired, or absent functioning

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The cerebrum is divided into two hemispheres and is further divided into four lobes per hemisphere. Which section of the brain controls and coordinates muscle movements?

cerebellum

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?

chewing

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson's disease and Huntington's disease is the development of ________ in clients with advanced Huntington's disease.

hallucinations and delusions

A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase?

preventing further neurologic damage