ATI Quiz: Medical-Surgical: Neurosensory – Flashcards
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A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure?
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Protect the client's head R: The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. the client is at greatest risk for injury from hitting his head; therefore, the first action is to protect the client's head from injury.
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A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dyreflexia?
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Report of headache R: Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.
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A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insidious (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI?
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Specific gravity R: Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, infection, or a tumor. It is a condition in which an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.
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A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment data the nurse should collect to determine a change in the client's neurologic status?
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Level of consciousness R: The nurse should apply the urgent vs. non urgent priority-setting framework. Using the framework, the nurse should consider urgent needs the priority because they pose more of a risk to the client. The nurse might also use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify the most urgent finding. Therefore, the priority assessment is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurological status.
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A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions?
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I will avoid bending over R: The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can result in intraocular hemorrhage.
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A nurse is reviewing the medical history of a client who is scheduled for magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure?
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The client has a pacemaker R: An MRI uses strong magnets and radio waves that are evaluated using computer technology to view three-dimensional images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medicinal implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the sting magnetic force can interfere with these devices obscure surrounding anatomical structures.
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A nurse assessing a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?
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Cheyne-Stokes R: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths, followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.
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A nurse is reviewing the laboratory result of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?
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Elevated protein R: An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase of protein in the cerebrospinal fluid.
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A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?
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Severe eye pain R: Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision headache, brow pain, and nausea and vomiting.
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A nurse is teaching a client who has a diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding the teaching?
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"An aura is sensory warning that a seizure is imminent." R: An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor.
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A nurse is assessing a client who has a closed head injury and received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?
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The client's serum osmolarity is 310 mOsm/L R: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 most/L is desired. A decrease in cerebral edema should result in a decrease in ICP.
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A nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. The nurse should include in the teaching that which of the following is an adverse affect of LASIK surgery?
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Dry eyes
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A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following information should the nurse include in the teaching? (Select all that apply)
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Driving can be dangerous due to loss of peripheral vision Laser surgery can help reestablish the flow of aqueous humor
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A nurse is providing teaching to the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority?
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Dysphagia
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A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS?
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Weakness of the distal extremities
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A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching?
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"You should avoid reading for 1 week."
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A nurse is providing teaching to a family of a client who has stage II Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching?
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Limit choices offered to the client
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A Nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions?
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Semi - Fowler's
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A nurse is assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?
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Widened pulse pressure
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A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?
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Darken the lights
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A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect?
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Difficulty with speech
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A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?
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Instill diluted alcohol solution into the ear after swimming
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A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?
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Feeling of fullness in the ear
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A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?
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Swelling behind the affected ear
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A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?
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The client rigidly extends his arms
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A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching?
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Avoid sudden movements
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A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching?
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A TIA can precede an ischemic stroke
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A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect?
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Weakness of the lower extremities
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A nurse in an acute care facility is preparing to admit a client who has myasthenia graves. Which of the following supplies should the nurse place at the client's bedside?
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Oral-nasal suction equipment
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A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement?
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Dysphagia
