Question 1 See full question
A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign
... [Show More] assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate?
Question 2 See full question
What should a nurse do when administering pilocarpine?
Question 3 See full question
A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin to a client with a history of seizures. As the LPN walks into the room, she hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do?
Question 4 See full question
A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction?
Question 5 See full question
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:
Question 6 See full question
A 70-year-old, previously well client asks the nurse, "I notice I have tremors. Is this just normal for my age?" What should the nurse tell the client?
Question 7 See full question
Following an infection, the client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for: (Select all that apply.)
Question 8 See full question
A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?
Question 9 See full question
The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
Question 10 See full question
Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?
Question 11 See full question
A client with glaucoma is to receive 3 gtt of acetazolamide in the left eye. What should the nurse do?
Question 12 See full question
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?
Question 13 See full question
A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, “Why am I unable to stop talking about these things? I know those days are gone forever.” Which response by the nurse conveys the best understanding of the client’s behavior?
Question 14 See full question
A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?
Question 15 See full question
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client:
Question 16 See full question
An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?
Question 17 See full question
After 5 days of hospitalization, a client who is receiving morphine sulfate for pain control asks for pain medication with increasing frequency and exhibits increased anxiety and restlessness. The vital signs are within normal ranges. What is a possible cause of this behavior?
Question 18 See full question
When determining how to administer analgesics to a client who has been receiving opiates for pain relief administered by injection, the nurse should consider using patient-controlled analgesia since it is more effective because:
Question 19 See full question
A client is receiving cyclobenzaprine for management of a herniated lumbar disk. Which finding indicates the drug is providing the intended relief?
Question 20 See full question
A client with a lumbar laminectomy ambulates for the first time after surgery and begins to feel faint. Which nursing action would be best until help arrives?
Question 21 See full question
After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated?
Question 22 See full question
A client returns from surgery after a submucosal resection with nasal packing in place. The nurse should first:
Question 23 See full question
The client reports that the nasal packing is uncomfortable and asks when it will be removed. The nurse should tell the client the nasal packing is usually removed:
Question 24 See full question
The nurse is instructing a client with Ménière’s disease how to recognize vertigo. The nurse should tell the client to notice:
Question 25 See full question
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:
Question 26 See full question
A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by:
Question 27 See full question
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?
Question 28 See full question
A nurse is giving discharge teaching to a client with an eye injury. Which statement about preventing eye injuries should the nurse include?
Question 29 See full question
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?
Question 30 See full question
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
Question 31 See full question
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
Remediation:
Question 32 See full question
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
Question 33 See full question
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?
Question 34 See full question
A client is receiving an I.V. infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Question 35 See full question
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?
Question 36 See full question
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?
Question 37 See full question
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
Question 38 See full question
A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?
Question 39 See full question
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?
Question 40 See full question
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
Question 41 See full question
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?
You Selected:
Question 43 See full question
A client with Parkinson's disease needs a long time to complete morning care, but becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's bestinitial response in this situation?
Question 44 See full question
The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?
Question 45 See full question
The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.
Question 46 See full question
A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which of the following actions is most important for the nurse to take to facilitate rehabilitation with eating?
Question 47 See full question
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays have not been read, so the nurse does not know whether the client has a cervical spinal injury. The nurse develops a plan of care and includes which of the following?
Question 48 See full question
A client recovering from Guillain Barré syndrome states, “I'm nervous that this disease will come back.” Which nursing diagnoses is most suggested by this comment?
Question 49 See full question
A nurse is preparing to administer phenytoin to a 99-lb (45 kg) client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be administered in the first dose? Record your answer as a whole number.
Question 50 See full question
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?
Question 1 See full question
A physician orders diazepam, 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true?
Question 2 See full question
A client with amyotrophic lateral sclerosis (ALS) is admitted with weight loss and malnutrition. He can swallow without difficulty. While caring for the client, the nurse discovers that his weight loss is related to his refusal to eat. The client states to the nurse that he would rather die than remain alive with this disease. How should the nurse intervene?
Question 3 See full question
A client with an inoperable brain tumor is brought to the hospital because the family can no longer care for the client at home. As the nurse provides care for the client, family members express their disappointment at not being able care for him/her at home as the client wished, since he/she did not want to die in the hospital. Which response by the nurse is best?
Question 4 See full question
According to hospital policy, a nurse in charge of a neurologic floor must facilitate discharges during a disaster event so clients involved in the disaster can be admitted promptly. After quickly reviewing the client census, the nurse identifies five postoperative clients who may be ready for discharge. What should the nurse do next?
Question 5 See full question
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?
Question 6 See full question
The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use?
Question 7 See full question
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:
Question 8 See full question
A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client's nursing care with the understanding that acute angle-closure glaucoma:
Question 9 See full question
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should first:
Question 10 See full question
The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate?
Question 11 See full question
Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin?
Question 12 See full question
The nurse is teaching a client to recognize an aura. The nurse should instruct the client to note:
You Selected:
Question 13 See full question
A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy?
Question 14 See full question
The nurse is to check a client’s gag reflex. The most effective technique for testing the gag reflex is to:
Question 15 See full question
For a neurologically injured client, the nurse should assess motor strength by:
Question 16 See full question
When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent:
Question 17 See full question
Which finding indicates that the victim of an automobile accident is comatose as a result of a toxic drug overdose?
Question 18 See full question
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:
Question 19 See full question
A caucasian female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?
Question 20 See full question
When obtaining the health history from a client with retinal detachment, a nurse expects the client to report:
Question 21 See full question
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:
Question 22 See full question
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?
Question 23 See full question
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?
Question 24 See full question
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?
Question 25 See full question
When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:
Question 26 See full question
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:
Question 27 See full question
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should:
Question 28 See full question
A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?
Remediation:
Question 29 See full question
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? [Show Less]