While walking in the hall, a hospitalized client has a tonic-clonic seizure. During the seizure the nurse's priority should be to:
Protect the client's head from injury
Hold the client's extremities firmly
Move the client immediately to a soft surface
Attempt to insert an airway between the client's teeth
A client sustains a vertebral fracture at the T1 level as a result of diving into shallow water. On admission to the emergency department a detailed neurologic assessment is performed. The nurse should expect to find:
Inability to move the lower arms
Normal biceps reflexes in the arms
Loss of pain sensation in the hands
Difficulty breathing due to a flaccid diaphragm
A 67-year-old client is diagnosed as having a right-sided brain attack (cerebrovascular accident) and is admitted to the hospital. When preparing to care for this client, the nurse should plan to:
Use a bed cradle to prevent dorsiflexion of the feet
Apply elastic stockings to prevent flaccid leg muscles
Do passive range-of-motion exercises to prevent muscle atrophy
Use a hand roll while supporting the left upper extremity on a pillow to prevent contractures
A 50-year-old client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, the nurse suspects the tumor is located in the:
Cerebellum
Parietal lobe
Basal ganglia
Occipital lobe
A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but is still incontinent of urine. To help reestablish bladder control, the nurse should encourage the client to:
Assume a standing position for voiding
Void every 4 hours and attempt to hold urine between set times
Attempt to void more frequently in the afternoon than in the morning
Drink a minimum of 4000 mL of fluid and divide it equally among the hours while awake
A 35-year-old male who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained and the results include a PCO2 of 33 mm Hg. It is most important for the nurse to:
Encourage the client to slow his breathing rate
Auscultate the client's lungs and suction if indicated
Advise the physician that the client needs supplemental oxygen
Report the results and continue to monitor for signs of increasing intracranial pressure
A client has ear surgery. Which is an early response that may be associated with possible damage to the motor branch of the facial nerve?
Bitter metallic taste
Dryness of the mouth
Inability to wrinkle the forehead
Sensation of pain behind the ear
Discharge planning for an ambulatory client with Parkinson's disease includes recommending equipment for home use that will help with activities of daily living. The most important equipment to help foster independence is:
A raised toilet seat
Side rails for the bed
A trapeze above the bed
Crutches for ambulation
A young female client goes to the physician because she has been experiencing fatigue and double vision. The physician suspects myasthenia gravis. When obtaining information from the client, the nurse should expect her to report that:
Her level of fatigue has been constant
The longer she rests, the weaker she feels
Her strength increases with progressive activity
The symptoms seem more severe in the evening
During the acute stage of Guillain-Barré syndrome, the most important nursing measure is the frequent assessment of the client's:
Urinary output
Sensation to touch
Neurologic status
Respiratory exchange
A 25-year-old client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. The therapeutic approach by the nurse that has the highest priority is:
Controlling intracranial pressure
Adding pads to the side of the bed
Administering prescribed antibiotics
Hydrating the client with 0.45% saline
When assessing a client with Parkinson's disease, a common adaptation the nurse would expect to find is:
Leaning toward the affected side
Blank facies without expression
Tremors of the hand on movement
Hyperextension of the affected extremity
During an exacerbation of multiple sclerosis a client complains of urinary urgency and frequency. The initial nursing measure should be to:
Palpate the suprapubic area
Begin teaching self-catheterization
Develop a plan to ensure high-fluid intake
Initiate a regimen to monitor urinary output
The nurse assesses a client for increasing intracranial pressure by monitoring the pulse pressure. The nurse understands that a client's pulse pressure is the:
Force exerted against an arterial wall
Disparity between the apical and radial rates
Difference between systolic and diastolic readings
Degree of ventricular contraction in relation to output
client with the diagnosis of multiple sclerosis had a sudden loss of vision and asks the nurse what caused it. The nurse explains that the temporary blindness was probably caused by:
Virus-induced iritis
Intracranial pressure
Closed-angle glaucoma
Optic nerve inflammation
A client with the diagnosis of multiple sclerosis develops hand tremors. When performing a physical assessment, the nurse should take into consideration that the tremors associated with multiple sclerosis usually occur when the client:
Is asleep
Is inactive
Attempts to do something
Becomes nervous or upset
The nurse begins planning for the discharge of a client who had a brain attack (cerebrovascular accident) with residual hemiparesis and hemianopia. Information that the nurse should include in the education program is the:
Importance of bed rest at home
Use of oxygen therapy at home
Significance of a safe environment
Need to decrease protein in the diet
To assist a client with Bell's palsy, it would be most appropriate for the nurse to:
Prepare the client for surgery
Tape the affected eyelid open
Teach facial exercises to the client
Record the symmetric progression of the paralysis
A client with expressive aphasia becomes frustrated and upset when attempting to communicate with the nurse. To help alleviate this frustration the nurse should:
Limit the client's contact with others to limit the frustration
Anticipate needs so that the client does not have to ask for help
Face the client, speaking loudly so that the client can hear better
Allow adequate time so that the client does not have to respond under pressure.
When teaching a client with a hemiparesis to ambulate with a cane, the nurse should instruct the client to:
Shorten the stride of the unaffected extremity
Lean the body toward the cane when ambulating
Advance the cane and the affected extremity simultaneously.
Hold the cane on the same side as the affected extremity and increase the base of support
A client has a tumor of the cerebellum. When considering the functions of this structure, the nurse should expect to observe an:
Unconscious state
Inability to execute voluntary movements
Absence of the knee-jerk and other reflexes
Inability to execute smooth, precise movements
The nurse recognizes that the most specific diagnostic test that the physician can perform for a client who is suspected of having myasthenia gravis would be:
An electromyography (EMG)
The pyridostigmine (Mestinon) test
The edrophonium chloride (Tensilon) test
A thorough history and physical assessment
When assessing a client with myasthenia gravis, the nurse would expect the client to demonstrate:
Partial improvement of muscle strength with mild exercise
Fluctuating weakness of muscles innervated by the cranial nerves
Little or no change in muscle strength regardless of therapy initiated
Dramatic worsening in muscle strength with anticholinesterase drugs
When talking with a client who has been diagnosed with myasthenia gravis, the nurse observes that the client has:
Problems with cognition
Difficulty swallowing saliva
Intention tremors of the hands
Nonintention tremors of the extremities
The priority nursing diagnosis for a client who is in myasthenic crisis would be:
Activity Intolerance
Impaired Physical Mobility
Ineffective Breathing Pattern
Disturbed Sensory Perception
A female client with myasthenia gravis is concerned about her unstable physical condition and generalized weakness. When planning for this client's care it would be most important to:
Encourage bed rest
Provide frequent rest periods
Point out the things she can do
Arrange for a relative to be present
An older client is admitted with a brain attack (cerebrovascular accident) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. The nurse should:
Have the client keep the head turned to the right
Instruct the staff to approach the client from the left side
Arrange the furniture so the door is in the right visual field
Teach the client to use head movements to scan the left field of vision
The nurse is evaluating sensory changes in a client whose spinal cord was severed at the level of T6 and T7. This evaluation process requires the:
Client to squeeze the nurse's hand
Nurse to monitor the client's vital signs
Client to state where the pinching sensation is felt
Nurse to observe the skin for color changes below the lesion
When caring for a person with myasthenia gravis the nurse must differentiate between myasthenic and cholinergic crises. The nurse should recognize that:
Atropine is used to treat cholinergic crisis
Tensilon causes transitory worsening of myasthenic crisis
Severe respiratory distress occurs with cholinergic crisis
Cholinergic crisis occurs with undermedication of anticholinesterase drugs
A 30-year-old homemaker with a 5-year history of myasthenia gravis is admitted to the hospital. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. Based on this client's diagnosis and status, the nurse should expect that the client's muscle:
Weakness will decrease after hot baths
Weakness will decrease with muscle use
Strength will improve immediately after meals
Strength will decrease with repeated muscle use
A 50-year-old widow with myasthenia gravis is living in a nursing home. She is receiving pyridostigmine bromide (Mestinon) to control symptoms but is beginning to experience increased difficulty in swallowing. The nursing intervention that would be most effective in preventing aspiration of food would be to:
Place a tracheostomy set in her room
Assess her respiratory status after meals
Change her diet order from soft foods to clear liquids
Coordinate her meals with the peak effect of her medication
A client is admitted to the hospital from the emergency department for observation because of an accident. Assessment reveals a sutured laceration on the scalp; stable vital signs; orientation to person, place, and time; and an intravenous line for circulatory access. When performing an assessment the nurse identifies a clear, watery drainage oozing from the client's right ear. Before notifying the physician, the best nursing action to take would be:
Testing the fluid for glucose and applying a sterile dressing
Positioning the client so that the unaffected ear is dependent
Covering the area with sterile gauze while applying slight pressure
Cleaning the outer ear with normal saline and inserting a clean cotton ball
A client has a generalized seizure at work and is brought to the emergency department. The question that is most useful to the nurse when planning care related to the client's seizure pattern would be:
"Is your job demanding or stressful most of the time?"
"Do you participate in any strenuous sports activities on a regular basis?"
"Were you aware of anything different or unusual just before your seizure began?"
"Does anyone in your family have a history of central nervous system health problems?"
Autonomic dysreflexia is a syndrome seen in clients with spinal cord injuries. The signs and symptoms include diaphoresis, pulsating headaches, and goosebumps. This syndrome may occur when the:
Client is upright on a tilt table
Myelin sheath is deteriorating
Large intestine becomes distended
Spinal cord is crushed rather than severed
A male client is admitted to the emergency department with a head trauma, resulting from a fall from a motorcycle. The client opens his eyes and withdraws appropriately in response to a painful stimulus, but he has no verbal response to stimuli. Using the Glasgow Coma Scale the nurse determines the client's score to be:
7
9
12
15
When caring for a client with a spinal cord injury, the nurse should plan to provide a high intake of fluid to help:
Prevent dehydration
Maintain electrolyte balance
Prevent urinary tract infection
Limit elevation of temperature
The finding the nurse should consider unusual when performing an assessment of a client for increased intracranial pressure would be:
Psychotic behavior
Jacksonian seizures
Nausea and vomiting
Rapid pulse and hypotension
A client arrives at the emergency department with neurologic deficits after a motor vehicle accident. Using the Glasgow Coma Scale, which responses should the nurse assess?