The nurse uses a dull object to stroke the lateral side of the underside of the left foot and moves upward to the great toe. When doing this, what reflex is the nurse testing?
Moro
Stepping
Babinski
Cremasteric
When preparing to assess the vagus nerve (cranial nerve X) of a client, the nurse will need:
A tuning fork
Tongue depressors
An ophthalmoscope
Cotton and a straight pin
The nurse in the neurologic clinic assesses for damage to the glossopharyngeal (ninth cranial) and vagus (tenth cranial) nerves by testing the client's ability to:
Shrug
Smell
Smile
Swallow
When assessing trigeminal nerve function, the nurse should evaluate:
Corneal sensation
Smiling and frowning
Ocular muscle movement
Shrugging of the shoulders
client expresses concern about insomnia. To promote sleep, which activity should the client be encouraged to do before bedtime?
Drink a glass of wine
Engage in mild exercise
Eat foods containing lysine
Perform deep-breathing exercises
A client, recently diagnosed with Bell's palsy, has many questions about the course of the disease. The nurse should explain that:
Pain occurs with transient ischemic attacks
Cool compresses decrease facial involvement
Most clients recover from the effects in 3 to 5 weeks
Body changes should be expected with residual effects
The nurse explains to a client with trigeminal neuralgia that a treatment that is effective on a temporary (6 to 18 months) basis is:
Weekly intravenous injections of cobra venom
A lidocaine injection of the ventral root of the eleventh spinal nerve
Microvascular decompression of the blood vessels at the nerve root
An alcohol injection of the peripheral branch of the fifth cranial nerve
A client with pain and paresis of the left leg is scheduled for electromyography. Before the test, the nurse should explain that:
The involved area will be shaved just before testing
The client's heart rate and rhythm will be monitored frequently
Needles will be inserted into the affected muscles during the test
The client will be kept in a recumbent position after the procedure
The nurse is aware that the teaching about myasthenic and cholinergic crises is understood when a client who has been diagnosed with myasthenia gravis states that a symptom common to both is:
Diarrhea
Salivation
Difficulty breathing
Abdominal cramping
When assessing the progress of a client being treated for myasthenia gravis, the nurse should expect:
Partial improvement of muscle strength with mild exercise
Fluctuating weakness of muscles innervated by the cranial nerves
Little change in muscle strength regardless of the therapy initiated
Dramatic worsening in muscle strength with anticholinesterase drugs
When assisting a client who has myasthenia gravis to bathe, the nurse notices that the client's arms become weaker with sustained movement. The nurse should:
Encourage the client to rest for short periods
Continue the bath while supporting the client's arms
Gradually increase the client's activity level each day
Administer a dose of pyridostigmine bromide (Mestinon)
A client with myasthenia gravis comes to the neurology clinic at 4 PM for a routine visit. During an assessment the nurse should expect the client to report:
Blurred vision along with episodes of vertigo
Tremors of the hands when attempting to lift objects
Partial improvement of muscle strength with mild exercise
Involvement of the distal muscles rather than the proximal muscles
During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse should evaluate that the teaching was effective when the client recognizes that it is important to:
Plan activities for later in the day
Eat meals in a semirecumbent position
Avoid people with respiratory infections
Take muscle relaxants when under stress
The nurse is teaching a client with myasthenia gravis how to prevent a myasthenic crisis. The nurse knows health teaching has been effective if the client says:
"I'll take an antihistamine at the first sign of a cold."
"I can skip a dose of Mestinon if it upsets my stomach."
"We've told our daughter not to let her cold keep her from visiting us."
"The doctor may need to adjust the dosage of my medication if I'm more active."
A client is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. The nurse should explain to the client that the diagnosis of myasthenia gravis will be confirmed if the administration of Tensilon produces a:
Brief exaggeration of symptoms
Prolonged symptomatic improvement
Rapid but brief symptomatic improvement
Symptomatic improvement of just the ptosis
The physician orders a diagnostic workup for a client who may have myasthenia gravis. The initial nursing goal for the client during the diagnostic phase should be that, "The client will:
"Adhere to a teaching plan."
"Achieve psychologic adjustment."
"Maintain present muscle strength."
"Prepare for the appearance of myasthenic crisis."
The most significant initial nursing observations that should be made about a client, who is suspected of having myasthenia gravis, include the:
Ability to chew and speak distinctly
Capacity to smile and close the eyelids
Effectiveness of respiratory exchange and ability to swallow
Degree of anxiety and concern about the suspected diagnosis
A client with myasthenia gravis, who is living in a nursing home, experiences inadequate symptomatic control with pyridostigmine bromide (Mestinon) and the physician begins long-term steroid therapy. When this type of therapy is being initiated, it is especially important for the nurse to ensure that the client:
Increases sodium intake
Is placed on protective isolation
Decreases fluid intake to 1000 mL daily
Is monitored for an exacerbation of symptoms
A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When planning for this client's care it would be most important for the nurse to plan to:
Space activities throughout the day
Restrict activities and encourage bed rest
Teach the limitations imposed by the disease
Have a member of the family stay and give the client support
The nurse identifies that a client exhibits the characteristic gait associated with Parkinson's disease. When recording on the client's record, the nurse should describe this gait as:
Ataxic
Shuffling
Scissoring
Asymmetric
While performing the history and physical examination of a client with Parkinson's disease, the nurse should assess the client for:
Frequent bouts of diarrhea
Hyperextension of the neck
A low-pitched and monotonous voice
A recent increase in appetite and weight gain
While assessing a client with Parkinson's disease, the nurse identifies bradykinesia when the client exhibits:
Muscle flaccidity
An intention tremor
Paralysis of the limbs
A lack of spontaneous movement
An older adult with a history of parkinsonism has some rigidity and tremors despite medication. At this time the client is admitted to the hospital with pneumonia. In view of the current medical problem and the rigidity, the nursing plan should include:
Gait training in physical therapy department
Isometric exercises every other hour while awake
Active range-of-motion exercises at least every 4 hours
Passive range-of-motion exercises at least once every 8 hours
A retired mailman with parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complains of some numbness in the left hand. The nurse should:
Make arrangements immediately for further medical evaluation
Refer the client to a physician if other neurologic deficits are present
Stress the importance of calling the family physician as soon as possible
Have the physician increase the dosage of the anticholinergic medication
The nurse might expect a client with multiple sclerosis to complain about the most common initial symptom, which is:
Diarrhea
Headaches
Skin infections
Visual disturbances
A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" The nurse's best response would be:
"Tell me about your fears regarding pain."
"Analgesics will be ordered to control the pain."
"Let's make a list of the things you need to ask the physician."
Pain is not a characteristic symptom of this disease process."
A 28-year-old woman has known for the past 6 years that she has multiple sclerosis. She has two children, one of whom is an active 2 1/2-year-old. The client is currently in remission. At the present time, it would be most important for the nurse to encourage the client to:
Schedule periodic quality time with her child
Provide support to other people with multiple sclerosis
Develop a flexible schedule for completion of routine daily activities
Meet with the psychotherapy group for people with multiple sclerosis
The nurse is reviewing treatment options for a client diagnosed with Guillain-Barré syndrome. Which procedure should the nurse discuss as a potential treatment option?
Hemodialysis
Plasmapheresis
Thrombolytic therapy
Immunosuppression therapy
During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, the nurse should expect that the client will manifest:
Diminished visual acuity
Increased muscular weakness
Pronounced muscular atrophy
Impairment in cognitive reasoning
The nurse is caring for a client with Guillain-Barré syndrome. For what essential care related to rehabilitation should the nurse prepare the client?
Physical therapy
Speech exercises
Fitting with a vertebral brace
Follow-up on cataract progression
A client asks for an explanation about glaucoma. The nurse explains that with glaucoma there is:
An increase in the pressure within the eyeball
An opacity of the crystalline lens or its capsule
A curvature of the cornea that becomes unequal
A separation of the neural retina from the pigmented retina
When obtaining the nursing history from a client who has open-angle (chronic) glaucoma, a complaint that the nurse should expect is:
Flashes of light
Intolerance to light
Seeing floating specks
Loss of peripheral vision
A 78-year-old woman who has just been diagnosed with primary open-angle glaucoma (POAG) refuses therapy. The nurse should discuss this with the client because if this condition is untreated it may lead to:
Cataracts
Blindness
Retinal detachment
Blurred distance vision
A client who has open-angle (chronic) glaucoma is scheduled for eye surgery to promote aqueous humor outflow. The nurse would know that the client understands the preoperative teaching about the first 24 hours after surgery when the client states, "I should:
"Cough every hour."
"Lie on my unaffected side."
"Move around freely in bed."
"Elevate the head of my bed."
An older adult has cataracts in both eyes. The left cataract is scheduled to be extracted in several days. The nurse should plan to instruct the client that:
"Both eyes will be covered for 24 hours after surgery."
"You must remember to take deep breaths and cough several times an hour."
"You may have to remain on bed rest for 3 to 4 days after your surgery."
"At night you will be wearing a hard patch over your operated eye for about a week."
After cataract surgery a client complains of feeling nauseated. The nurse should:
Give the client some dry crackers to eat
Administer the antiemetic drug as ordered
Explain that this is expected following surgery
Instruct the client to deep breathe until the nausea subsides
After a left cataract extraction, a client complains of severe discomfort in the operated eye. The nurse recognizes that this is a problem that may be caused by:
Hemorrhage into the eye
Expected postoperative discomfort
Isolation related to sensory deprivation
Pressure on the eye from the protective shield
A client is prepared for discharge from an ambulatory surgical unit after cataract removal with an intraocular lens implant. The statement by the client that suggests to the nurse that the discharge teaching is effective is:
"I'm driving home since I feel so good."
"I can't wait until I get home to wash my hair."
"I can expect to see bright flashes of light for awhile."
"I'll call the surgeon immediately if my eye becomes painful."
After cataract surgery, a client is taught how to self-administer eyedrops before discharge. The nurse approves the technique when the client:
Holds the dropper tip above the eye
Places the drops on the cornea of the eye
Raises the upper eyelid with gentle traction
Squeezes the eye shut after instilling the eyedrops
After an automobile accident, a client complains of seeing frequent flashes of light. Which condition should the nurse suspect?
Glaucoma
Scleroderma
Detached retina
Cerebral concussion
After surgery to repair a retinal detachment, an older adult client returns to the postanesthesia care unit with the affected eye patched. During the first 4 hours after surgery, the nurse should notify the physician if the client:
Has not voided
Cannot open the eye
Becomes disoriented
Complains of sharp pain in the eye
A client who had a retinal detachment has a scleral buckling procedure to attempt to reattach the retina. Before the client is discharged home, the nurse should:
Instruct the client to wear dark glasses after the patch is removed
Tell the client that usual activities can be resumed within 2 weeks
Explain to the client that reading will help strengthen the eye muscles
Reassure the client that the glasses worn before surgery can still be worn
When performing a neurologic check on a client with a head injury, the nurse identifies a diminished corneal reflex. Appropriate nursing care for an absent corneal reflex includes:
Irrigating the eye every 4 hours
Checking the corneal reflex every hour
Instilling artificial tears whenever necessary
Alternately taping the eyelids open and closed every 2 hours
The nurse uses the Glasgow Coma Scale to assess a client with a head injury that resulted from a snowboarding accident. The nurse identifies that the client is in a coma when the Glasgow Coma Scale score is:
6
9
12
15
After an automobile accident a client, who is unconscious and exhibiting decerebrate posturing, is brought to the emergency department. When assessing this client the nurse should expect to observe:
Hyperextension of both the upper and lower extremities
Spastic paralysis of both the upper and lower extremities
Hyperflexion of the upper extremities and hyperextension of the lower extremities
Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities
A client is admitted to the hospital after sustaining a head injury. The most reliable sign that this client is experiencing an increase in intracranial pressure would be a slowly:
Rising respiratory rate
Narrowing pulse pressure
Decreasing level of consciousness
Increasing diastolic blood pressure
During the immediate post-trauma period after injury to the frontal lobe of the brain, the nurse should place a client in the:
Supine position
Side-lying position
Low-Fowler's position
Trendelenburg position
The nurse in the emergency department prepares a checklist before transferring an unconscious client with a head injury to the neurologic trauma unit. The nursing action that has primary importance is:
Notifying the receiving unit of the transfer
Having the client's records ready for transfer
Verifying that the family has been notified of the transfer
Checking that a bag-valve mask is available during the transfer
A client who has sustained a severe head injury in a diving accident remains unconscious. In addition, the nurse observes bleeding from the left ear, as well as rhinorrhea. The nurse is aware that the drainage from the ear and nose indicates:
Contusion
Concussion
Nose fracture
Basilar fracture
client with a severe head injury is being observed by the nurse for increasing intracranial pressure. The finding most indicative of increasing intracranial pressure would be:
Polyuria
Tachypnea
Increased restlessness
Intermittent tachycardia
A 28-year-old is brought to the emergency department unconscious after an accident. The client's pupils are equal and responsive to light. As part of the neurologic assessment, the nurse applies a painful stimulus to the client's left lower leg. An expected response would be to:
Extend the leg
Withdraw the leg
Make no movement
Plantar-flex the left foot
A client has had spinal anesthesia for surgery. On the second day after surgery the client complains of a headache. The nurse should:
Begin an early ambulation program
Supply the client with several containers of juice
Remove any elastic antiembolism stockings being worn
Assist the client to sit at the bedside with the feet dangling
A 26-year-old, admitted with the diagnosis of subarachnoid hemorrhage, exhibits aphasia and hemiparesis. These neurologic deficits, which may be present immediately after a subarachnoid hemorrhage, are primarily caused by:
Blood loss
Tissue death
Vascular spasms
Electrolyte imbalance
The nurse should plan to position a client who has experienced a subarachnoid hemorrhage:
In the supine position
On the unaffected side
With the head of the bed elevated
With sandbags on either side of the head
After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow the nurse should:
Clear the ear of draining fluid
Monitor the serum carbon dioxide
Discontinue anticonvulsant therapy
Elevate the head of the bed 30 degrees
When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated would be:
Lubricating the skin with baby oil
Suctioning the oropharynx routinely
Elevating the head of the bed 20 degrees
Cleansing the eyes every 4 hours with normal saline
A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. The nurse should first:
Elevate the head of the bed
Administer an osmotic diuretic
Reduce the flow rate of IV fluid
Notify the physician of the finding
A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. Postoperatively, the position that would be most appropriate for this client is:
High-Fowler's with knee gatch raised
Flat with a small pillow under the nape of the neck
Head of the bed elevated 20 degrees with the head turned to the operative side
Head of the bed elevated 45 degrees with a large pillow under the head and shoulders
A client has surgery for the creation of burr holes after sustaining head trauma from a fall and is at risk for developing an infection. An early clinical manifestation of meningeal irritation for which the nurse should assess the client is:
Sunset eyes
Kernig's sign
Homans' sign
Plantar reflex
After 3 months of rehabilitation after a craniotomy, a female client is still having some motor speech difficulty. To promote the client's use of speech the nurse should:
Correct her mistakes immediately
Support her efforts to communicate
Reexplain why she is having difficulty speaking
Address her in simple words with short sentences
A client has a history of progressive carotid and cerebral atherosclerosis and transient ischemic attacks (TIAs). The nurse understands that TIAs are:
Temporary episodes of neurologic dysfunction
Transient attacks caused by multiple small emboli
Several periods of exacerbations alternating with remissions
Ischemic attacks that result in progressive neurologic deterioration
A client has carotid atherosclerotic plaques, and a right carotid endarterectomy is performed. Two hours after surgery the client demonstrates progressive hypotension. The nurse should:
Increase the IV flow rate
Raise the head of the bed
Notify the physician immediately
Put the client in a slight Trendelenburg position
After a carotid endarterectomy, the client should be monitored for the complication of cranial nerve dysfunction. To monitor for this complication, the nurse should assess the client for:
Labored breathing
Edema of the neck
Difficulty in swallowing
Alteration in blood pressure
A client is admitted to the hospital with weakness in the right extremities and a slight speech problem. Vital signs are normal. During the first 24 hours, the nurse should give priority to:
Checking the client's temperature
Evaluating the client's motor status
Monitoring the client's blood pressure
Obtaining the client's urine for a urinalysis
A client having a brain attack (CVA) is brought to the emergency department. The vital signs are P, 78; R, 16; and BP, 120/80. The change in this client's vital signs that would indicate increasing intracranial pressure (ICP) requiring notification of the physician would be:
P, 120; R, 16; BP, 80/60
P, 50; R, 22; BP, 140/60
P, 60; R, 18; BP, 126/96
P, 56; R, 20; BP, 130/110
On the evening before discharge from the hospital, a client has a hypertensive crisis and a brain attack (CVA). Initially the nurse should place the client in a:
Supine position
Contour position
Side-lying position
Trendelenburg position
Initially after a brain attack (CVA), a client's pupils are equal and reactive to light. Later the nurse assesses that the right pupil is reacting more slowly than the left and the systolic blood pressure is beginning to rise. The nurse recognizes that these adaptations are suggestive of:
Spinal shock
Hypovolemic shock
Transtentorial herniation
Increasing intracranial pressure
To prevent a client, who has had a brain attack (CVA) 2 days ago, from developing plantar flexion the nurse should:
Place a pillow under the thighs
Maintain the feet at right angles to the legs
Elevate the knee gatch to a 45-degree angle
Encourage active range of motion of all joints
A female client manifests right-sided hemianopia as a result of a brain attack (CVA). The nurse should:
Correct the client's misuse of equipment
Instruct the client to scan her surroundings
Provide tactile stimulation to the client's affected extremities
Teach the client to look at the position of her left extremities
The husband of a client with aphasia as a result of a brain attack (CVA) asks whether his wife's speech will ever return. The nurse should respond:
"You will have to ask your physician."
"It should return to normal in 2 or 3 months."
"It is hard to say how much improvement will occur."
"This will probably be the extent of her speech from now on."