Neurological Disorders (2)

A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make?

"It must be hard to see your mother so ill and upset."

A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions?

A sensory warning that a seizure is imminent

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

• Encourage fluid intake.

• Monitor the puncture site for hematoma.

A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

"Have you had a recent upper respiratory infection?"

A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic–clonic seizure. Which of the following interventions should the nurse take?

Place a pillow under the client's head.

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

Suction saliva from the client's mouth.

A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

Small drops of clear fluid in left ear

A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching?

Take the medication 45 minutes before eating.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first?

Check the client's temperature.

A nurse caring for a client who is recovering from a stroke. The client states "I feel like less of a man. My wife says she is thankful I am alive but I'm sure this is not how she expected us to spend our retirement years." Which of the following is an appropriate response?

"In what ways do you feel like you are less of a man?"

A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose.

A nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions should the nurse take?.

Elevate the head of the bed 30°.

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities?

Checking pupillary responses to light

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

Plantar flexion of the legs

When checking a patients gag reflex the nurse understands they are assessing which cranial nerve?

Glossopharyngeal

An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. While performing a neurological examination, which of following findings is the earliest indicator of the client's cerebral status?

Level of consciousness

A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take?

Attempt to determine what the client was looking for.

A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Lethargy

A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?

Forgetfulness gradually progressing to disorientation

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Prevent bladder distention.

A nurse is contributing to the plan of care for a client who has diabetes insipidus. Which of the following interventions should the nurse include?

Administer desmopressin.

A nurse is collecting data from a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Tachycardia

A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

• Provide a suction setup at the bedside.

• Elevate the side rails when in bed.

• Keep an oxygen setup at the bedside.

A nurse is modifying the diet of a client who has Parkinson's disease and a prescription for selegiline, a monamine oxidase inhibitor (MAOI). Which of the following foods should the nurse eliminate from the client's diet?

Cheddar cheese

A nurse is collecting data from a client who has Parkinson's disease and is experiencing bradykinesia. Which of the following findings should the nurse expect?

Slurred speech

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.)

• Disclosure of the treatment is provided

• Client understands the surgical procedure

• Voluntary consent is given

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to.

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

The client requires total nursing care.

A nurse is contributing to the plan of care for a client who is having headaches following the administration of a spinal anesthetic during surgery. Which of the following interventions should the nurse include in the plan of care?

Encourage increased intake of fluids.

A nurse assisting with the care of a client who is receiving treatment following a motor vehicle crash. Which of the following actions should the nurse take to determine the client's level of alertness?

Check the client's eye opening in response to verbal stimuli.

A nurse is reinforcing discharge instructions with a client who has multiple sclerosis (MS). Which of the following instructions should the nurse include?

"Implement a schedule to include periods of rest."

A nurse is preparing home instructions for a client who has epilepsy. Which of the following information should the nurse include in the teaching?

Take showers rather than tub baths.

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Postictal phase

A nurse is reinforcing teaching to the family of a client who has Parkinson's disease. Which of the following instructions should the nurse include?

Provide the client a cane.

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Hypertension