1.Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client’s mouth with a padded tongue blade. 4. Cleaning the client’s mouth and teeth with a toothbrush. 2. A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for A STAT computer tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult. 3. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? 1. Current medications. 2. Complete physical and history. 3. Time of onset of current stroke. 4. Upcoming surgical procedures. 4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s: 1. Pulse 2. Respirations 3. Blood pressure 4. Temperature 5. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level 2. Pupil size and pupillary response 3. Bowel sounds 4. Echocardiogram 6. What is the expected outcome of thrombolytic drug therapy? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage 7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta-blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication. 8. Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female. 9. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dl. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mmHg. 4. The presence of bronchogenic carcinoma. 10. The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client’s waist prior to ambulating. 2. The assistant places the client on the back with the client’s head to the side. 3. The assistant places her hand under the client’s right axilla to help him/her move up in bed. 4. The assistant praises the client for attempting to perform ADL’s independently. 1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? 1. Reposition the client to avoid neck flexion 2. Administer 1 g Mannitol IV as ordered 3. Increase the ventilator’s respiratory rate to 20 breaths/minute 4. Administer 100 mg of pentobarbital IV as ordered. 2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid Dilantin administration can cause cardiac arrhythmias. 3. Dilantin should be mixed in dextrose in water before administration. 4. Dilantin should be administered through an IV catheter in the client’s hand. 3. A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? 1. Evaluate urine specific gravity 2. Anticipate treatment for renal failure 3. Provide emollients to the skin to prevent breakdown 4. Slow down the IV fluids and notify the physician 4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). 2. Emergent; the client is poorly oxygenated. 3. Normal 4. Significant; the client has alveolar hypoventilation. Frequent swallowing 3. After a hypophysectomy. Which of the following nursing interventions should be done first? 1. Hemiparesis 3.5. vasopressin is given IM for which of the following reasons? 1. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage. Call for an immediate chest x-ray 3. Bloody drainage from the ears 2. Guaiac-positive stools 4. A client comes into the ER after hitting his head in an MVA. Assess full ROM to determine extent of injuries 2. Hematuria 6. which may be shown by which of the following signs? 1. A client with a C6 spinal injury would most likely have which of the following symptoms? 1. 7. Open the airway with the head-tilt-chin-lift maneuver 8. Paraplegia 4. He’s alert and oriented. Immobilize the client’s head and neck 4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. Tetraplegia . To prevent syndrome of inappropriate antidiuretic hormone (SIADH) 3. Aphasia 2. To treat growth failure 2. To reduce cerebral edema and lower intracranial pressure 4. Place the client flat in bed 2. pulse 48.9. A client is admitted with a spinal cord injury at the level of T12. Neurological deficit 3. a client with C8 tetraplegia develops a blood pressure of 80/40. and RR of 18. Methylprednisolone (Solu-Medrol) 4. Pulse ox readings 4. The client’s feelings about the injury 10. Hemorrhagic shock 3. Assess patency of the indwelling urinary catheter . Neurogenic shock 4. A 22-year-old client with quadriplegia is apprehensive and flushed. Autonomic dysreflexia 2. Which of the following medications would be used to control edema of the spinal cord? 1. A 30-year-old was admitted to the progressive care unit with a C5 fracturefrom a motorcycle accident. Which of the following nursing interventions should be done first? 1. Which of the following assessments would take priority? 1. Pulmonary embolism 11. He has limited movement of his upper extremities. Bladder distension 2. The nurse suspects which of the following conditions? 1. Sodium bicarbonate 12. Acetazolamide (Diamox) 2. with a blood pressure of 210/100 and a heart rate of 50 bpm. While in the ER. Furosemide (Lasix) 3. Which of the following nursing interventions should be done first? . A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? 1. Venous bleeding from the arachnoid space 16. Rupture of the carotid artery 3. To immobilize the cervical spine 3. To hasten wound healing 2. Schedule intermittent catheterization every 2 to 4 hours 3. Thromboembolism from a carotid artery 4. Perform a straight catheterization every 8 hours while awake 4. Laceration of the middle meningeal artery 2. Insert an indwelling urinary catheter to straight drainage 2. Give one SL nitroglycerin tablet 4. To hold bony fragments of the skull together 14. Raise the head of the bed immediately to 90 degrees 13. A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. To prevent autonomic dysreflexia 4. 15. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? 1. The underlying cause of epidural hematoma is usually related to which of the following conditions? 1. A 23-year-old client has been hit on the head with a baseball bat. Perform Crede’s maneuver to the lower abdomen before the client voids.3. The nurse notes clear fluid draining from his ears and nose. Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? 1. An interval when the client has a “warning” symptom. An interval when the client is alert but can’t recall recent events 3. the nurse teaches the guardian to observe for a lucid interval. A client with a brain injury 2. An interval when the client’s speech is garbled 2. 18. such as an odor or visual disturbance. Absence of pain sensation in chest 2. Urinary continence . Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? 1. Spasticity 3. Insert nasal and ear packing with sterile gauze 17. A client with a stroke 19. Check the fluid for dextrose with a dipstick 3. An interval when the client is oriented but then becomes somnolent 4. When discharging a client from the ER after a head trauma. A client with a herniated nucleus pulposus 3. Position the client flat in bed 2. Which of the following statements best described a lucid interval? 1. Suction the nose to maintain airway patency 4.1. Spontaneous respirations 4. A client with a high cervical spine injury 4. Put the client in the high-Fowler’s position 22. the nurse should perform which of the following interventions? 1. Which of the following conditions would the nurse anticipate during the acute phase? 1. Hypervolemia 3. Neurogenic shock 4. Neurogenic shock 4. pulse 34. Sepsis 23. During an episode of autonomic dysreflexia in which the client becomes hypertensive. Decerebrate posturing . Put the client in the Trendelenburg’s position 4. Elevate the client’s legs 2. A nurse assesses a client who has episodes of autonomic dysreflexia. Absent corneal reflex 2. Put the client flat in bed 3.20. A client has a cervical spine injury at the level of C5. and flaccid paralysis of the lower extremities. Autonomic dysreflexia 2. Which of the following conditions can cause autonomic dysreflexia? 1. Headache 2. dry skin. Which of the following conditions would most likely be suspected? 1. Noxious stimuli 21. A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40. Lumbar spinal cord injury 3. Which of the following symptoms would also be anticipated? 1. Which neurotransmitter is responsible for may of the functions of the frontal lobe? . and place. time. “Expect profuse vomiting for 24 hours after the injury.” 27. “Measure the quantity of urine. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. “Gently rotate the catheter during removal. Movement of only the right or left half of the body 4. Decreased urine output or oliguria 2.” 3.” 4. Hypertension and bradycardia 3.” 26. the nurse gives which of the following instructions? 1. Respiratory depression 4. “Clean the meatus from back to front.” 2.” 3. “Wake him every hour and assess his orientation to person. The need for mechanical ventilation 24. When discharging him to the care of his mother. An 18-year-old client was hit in the head with a baseball during practice. Symptoms of shock 25.3. “Clean the meatus with soap and water. Which of the following instructions should be given? 1.” 4. “Notify the physician immediately if he has a headache. “Watch him for keyhole pupil the next 24 hours. A 40-year-old paraplegic must perform intermittent catheterization of the bladder.” 2. Norepinephrine 28. a 36-year-old man sustains a C6 fracture with spinal cord transaction. Quadriplegia and loss of respiratory function . After falling 20’. Percent of functional brain tissue 29. Epidural hematoma 4. Subdural hematoma 2. Subarachnoid hemorrhage 3. Which type of head injury does this finding suggest? 1. Activity of the brain 4. The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. GABA 3. Sites of brain injury 3. A client arrives at the ER after slipping on a patch of ice and hitting her head. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? 1. Extent of intracranial bleeding 2. A CT scan of the head shows a collection of blood between the skulland dura mater. Histamine 4. Contusion 30.1. Quadriplegia with gross arm movement and diaphragmatic breathing 2. Dopamine 2. Which other findings should the nurse expect? 1. Desmopressin (DDAVP. Stimate) 2. The client’s urine output for the previous shift was 3000 ml. Loss of bowel and bladder control 31. By inserting a oropharyngeal airway 3. Paraplegia with intercostal muscle loss 4. and a blood pressure of 162/96. By performing a jaw-thrust maneuver 4. Which of the following nursing interventions would be appropriate for this client? Select all that apply.3. Upon assessment. Administer antihypertensive medication 6. chin-lift maneuver 32. By performing the head-tilt. Place the client in a supine position with legs elevated 33. The client reports a severe. the nurse notes flushed skin. How should the first- responder open the client’s airway for rescue breathing? 1. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. A cervical spine injury is suspected. Use a fan to reduce diaphoresis 4. 1. diaphoresis above the T5. A 20-year-old client who fell approximately 30’ is unresponsive and breathless. pounding headache. Elevate the HOB to 90 degrees 2. Loosen constrictive clothing 3. Dexamethasone (Decadron) . Assess for bladder distention and bowel impaction 5. The nurse is caring for a client with a T5 complete spinal cord injury. By inserting a nasopharyngeal airway 2. The nurse implements a new physician order to administer: 1. Hyperactive bowel sounds 4. The nurse takes quick action.3. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. A flattened abdomen 2. The client now has lost consciousness again. Mannitol (Osmitrol) 34. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? . The nurse is planning care for the client in spinal shock. Skull fracture 2. knowing this is compatible with: 1. Concussion 3. Limiting bladder catheterization to once every 12 hours 3. Strict adherence to a bowel retraining program 2. Epidural hematoma 35. Hematest positive nasogastric tube drainage 3. The nurse is caring for the client in the ER following a head injury. Preventing unnecessary pressure on the lower limbs 37. The nurse monitors for GI complications by assessing for: 1. The nurse would avoid which of the following measures to minimize the risk of recurrence? 1. Keeping the linen wrinkle-free under the client 4. The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The client momentarily lost consciousness at the time of the injury and then regained it. Subdural hematoma 4. Ethacrynic acid (Edecrin) 4. A history of diarrhea 36. Inability to elicit a Babinski’s reflex 4.4. A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. 38. Using vasopressor medications as prescribed 3. Positive reflexes 2.5) 2. the nurse’s actions (Number 1 being the first priority and number 5 being the last priority). The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury.1. Applying Teds or compression stockings. Which of the following observations by the nurse indicates that spinal shock persists? 1. Moving the client quickly as one unit 4. Contact the physician 4. Hyperreflexia 3. Keeping the client on a stretcher 2.1. Check for bladder distention (2. The nurse minimizes the risk of compounding the injury most effectively by: 1. Logrolling the client on a firm mattress 3. The nurse is caring for a client admitted with spinal cord injury. Loosen tight clothing on the client 5. After checking the client’s vital signs. 1. Raise the head of the bed 3. Monitoring vital signs before and during position changes 2. Administer an antihypertensive medication . Placing the client on a Stryker frame 39. list in order of priority. Logrolling the client on a soft mattress 4. Reflex emptying of the bladder 40.3. 41. A client has signs of increased ICP. Decreasing body temperature 42. irregular respirations 2. shallow respirations 3. Which of the following is an early indicator of deterioration in the client’s condition? 1. Administer low-dose barbiturate 3. Decreasing systolic blood pressure 3. Decrease in the pulse rate 3. Encourage the client to hyperventilate 4. Dilated. Asymmetric chest expansion 4. Restrict fluids 44. Which of the following would be a priority for the nurse to monitor? 1. Unequal pupil size 2. Give the client a warming blanket 2. Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1. Nasal flaring 43. Slow. Widening pulse pressure 2. Rapid. Tachycardia 4. Decrease in LOC . fixed pupil 4. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. A client is at risk for increased ICP. 45. Which nursing intervention protects the client without increasing her ICP? 1. dorsiflexion of feet 4. Supination of arms. wrists. Place her in a jacket restraint 2. Which action would be most appropriate? 1. 4. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. 47. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. Back arched. Tuck her arms and hands under the draw sheet 4. rigid extension of all four extremities. Count the rate to be sure the ventilations are deep enough to be sufficient 2. 3. Wrap her hands in soft “mitten” restraints 3. Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows. rigid flexion of all four extremities with supination of arms and plantar flexion of the feet 3. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score. Apply a wrist restraint to each arm 46. which of the following is contraindicated when positioning the client? . Check deep tendon reflexes to determine the best motor response 48. Back hunched over. and fingers 2. Call the physician to adjust the ventilator settings. and projectile vomiting. 1. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising? 1. Develop a discharge plan. Administer phenytoin (Dilantin) 200 mg PO daily. nature of seizure activity. Absent corneal reflex 50. Document the onset time. 3. Log rolling or turning as a unit when turning 4. 2. Teach patient about the need for good oral hygiene. Dilated nonreactive pupils 3. 4. Which findings would the nurse assess? Check all that apply. nuchal rigidity. Keeping the client flat on one side or the other 2. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? 1. Deep tendon reflexes 4. Decerebrate posturing 2. Vomiting continues 2. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache.1. Keeping the head in neutral position 49. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. and postictal behaviors for all seizures. Elevating the head of the bed to 30 degrees 3. Intracranial pressure (ICP) is increased . A client has been pronounced brain dead. including physician visits and referral to the Epilepsy Foundation. 1. Urine output increases 2.3. To draw water into the vascular system to increase blood pressure 3. 25 mm Hg 3. To prevent acute tubular necrosis 3. Sodium depletion . Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? 1. 120/80 mm Hg 5. with dilation of the ipsilateral pupil. Which of the following values is considered normal for ICP? 1. The client needs mechanical ventilation 4. 0 to 15 mm Hg 2. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? 1. To promote osmotic diuresis to decrease ICP 4. The physician orders mannitol for which of the following reasons? 1. BUN and creatinine levels return to normal 4. To reduce intraocular pressure 2. 35 to 45 mm Hg 4. A client with a subdural hematoma becomes restless and confused. Pupils are 8 mm and nonreactive 3. Systolic blood pressure remains at 150 mm Hg 4. Ataxia and confusion 2. Blood is anticipated in the cerebrospinal fluid (CSF) 2. Widened pulse pressure 7. Parietal 4. Problems with memory and learning would relate to which of the following lobes? 1. The nurse is assessing the motor function of an unconscious client. Frontal 2. Bradycardia 2. Temporal 8. Urinary incontinence 6. your client couldn’t feel the temperature of a hot oven. Pressure on the orbital rim . Occipital 3.3. While cooking. Large amounts of very dilute urine 3. Tonic-clonic seizure 4. Occipital 3. The nurse would plan to use which of the following to test the client’s peripheral response to pain? 1. Restlessness and confusion 4. Which of the following signs and symptoms of increased ICP after head trauma would appear first? 1. Parietal 4. Temporal 9. Which lobe could be dysfunctional? 1. Sternal rub 2. Frontal 2. Cold water is injected into the left auditory canal. Increasing temperature. An intact brainstem 4. Brain death 12. Squeezing the sternocleidomastoid muscle 4. The nurse would plan to place the client in which position for the procedure? 1. increasing blood pressure. Increasing temperature. increasing pulse. Nail bed pressure 10. The nurse is caring for the client with increased intracranial pressure. decreasing pulse. 11. decreasing respirations. with a pillow under the hip 3. Prone. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. Prone. increasing respirations. A temporal lesion 3. decreasing blood pressure. Side-lying. 3. increasing respirations. decreasing blood pressure. A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. The client is having a lumbar puncture performed. . with legs pulled up and head bent down onto the chest 2. 2. decreasing pulse. with a pillow under the abdomen. Decreasing temperature. The nurse understands that this indicates the client has: 1. Side-lying. The nurse would note which of the following trends in vital signs if the ICP is rising? 1.3. in a slight Trendelenburg’s position 4. A cerebral lesion 2. Tolerate the pain 2. decreasing respirations. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? . Keeping extraneous noise to a minimum 3. Performing treatments quickly 16.4. Which of the following would be most appropriate to institute? 1. Escape the source of pain 4. A client is arousing from a coma and keeps saying. increasing blood pressure. increasing pulse. Absence of nuchal rigidity 4. Decrease the perception of pain 3.” The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: 1. A positive Brudzinski’s sign 2. 13. “Just stop the pain. A negative Kernig’s sign 3. Allowing the child to play in the bathtub 4. A Glascow Coma Scale score of 15 14. During the acute stage of meningitis. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: 1. Decreasing temperature. Divert attention from the source of pain. Limiting conversation with the child 2. a 3-year-old child is restless and irritable. 15. Cyanosis 4. a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? 1. Edema 3. Bladder infection 2. Middle ear infection 3. 1. Fractured clavicle 4. A lumbar puncture is performed on a child suspected of having bacterial meningitis. Head tilt 2. Increased appetite 6. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. Cloudy CSF. and decreased glucose . elevated protein. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Lethargy 5. Vomiting 3. Polydipsia 4. decreased protein. CSF is obtained for analysis. Dyspnea on exertion 17. When interviewing the parents of a 2-year-old child. The nurse is assessing a child diagnosed with a brain tumor. Hemorrhagic skin rash 2. Increased pulse 19. Septic arthritis 18. Cloudy CSF. and decreased glucose 2.1. which of the following would be included in the plan of care? 1. Rigid extension and pronation of the arms and legs 3. Clear CSF. Negative Kernig’s sign 23. Negative Brudzinski’s sign 3. Positive Kernig’s sign 2. A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. Maintain neutropenic precautions 21. Rigid pronation of all extremities 4. Flaccid paralysis of all extremities 22. On assessment of the child. and elevated protein 20. and decreased glucose 4. decreased pressure. A nurse is planning care for a child with acute bacterial meningitis. the nurse would expect to note which of the following if this type of posturing was present? 1. Based on the mode of transmission of this infection. Maintain enteric precautions 3. Abnormal flexion of the upper extremities and extension of the lower extremities 2. No precautions are required as long as antibiotics have been started 2. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics 4. Clear CSF.3. elevated protein. Which of the following assessment data indicated nuchal rigidity? 1. Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? . Positive homan’s sign 4. Natural affinity of the CNS to certain pathogens 24. Occlusion or narrowing of the CSF pathway 4. Brain abscesses caused by a variety of pyogenic organisms 4. Balance and equilibrium. Complete admission assessment.1. Ischemic infarction of cerebral tissue 2. Lack of acquired resistance to the various etiologic organisms 3. 4. D. 2. Congenital anatomic abnormality of the meninges 2. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). 1. The client is intubated and placed on mechanical ventilation to help . 3. You are preparing to admit a patient with a seizure disorder. Thinking and reasoning. Which of the following actions can you delegate to LPN/LVN? 1. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus. Which of the following pathologic processes is often associated with aseptic meningitis? 1. Place a padded tongue blade at bedside. Cerebral ventricular irritation from a traumatic brain injury 25. Body temperature control. B. Childhood diseases of viral causation such as mumps 3. the nurse would anticipate that the client has problems with: A. Visual acuity. Set up oxygen and suction equipment. Pad the side rails before patient arrives. 2. C. Headaches. a young man age 18 is admitted to the emergency department. Frequent episodes of double vision. To prevent a further rise in ICP caused by suctioning. Lidocaine (Xylocaine) D.reduce ICP. D. Which intervention would be the most dangerous for the client? A. the nurse expects the client to report: A. Ineffective airway clearance . Elevate the head of his bed. 4. C. the nurse anticipates administering which drug endotracheally before suctioning? A. Mannitol (Osmitrol) C. He’s unconscious and his pupils are nonreactive. D. Furosemide (Lasix) 3. A recent driving accident while changing lanes. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis? A. Place him on mechanical ventilation. C. Light flashes and floaters in front of the eye. B. After striking his head on a tree while falling from a ladder. Perform a lumbar puncture. Give him a barbiturate. When obtaining the health history from a male client with retinal detachment. B. 5. Imbalanced nutrition: Less than body requirements B. nausea. Phenytoin (Dilantin) B. and redness of the eyes. Give the client privacy during meals. Sensory function 8. This test assesses which of the following? A.C. a male client with a seizure disorder develops status epilepticus. C. The physician orders diazepam(Valium) 10 mg I. if needed and prescribed? A. blurred vision. Cerebellar function B. Shortly after admission to an acute care facility.V. D. In 10 to 15 minutes C. Impaired urinary elimination D. B. Fill out the menu for the client. Stay with the client and encourage him to eat. Cerebral function D. 7. To encourage adequate nutritional intake for a female client with Alzheimer’s disease. In 30 to 45 seconds B. and photophobia in her right eye. In 30 to 45 minutes D. irregular. nonreactive pupil — a condition . A female client complains of periorbital aching. Risk for injury 6. In 1 to 2 hours 9. Intellectual function C. The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. How soon can the nurse administer the second dose of diazepam. tearing. Help the client fill out his menu. stat. the nurse should: A. Ophthalmologic examination reveals a small. Adrenergic blocker D.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour.5% ointment to be placed in the conjunctival sacs of . Assessing level of consciousness 11. They tell the nurse. Assessing the pupils C. where he receives emergency care for the corneal injury. His coworkers irrigate his eyes with water for 20 minutes. two drops of 0. He has a large contusion on his left chest and a hematoma in the left parietal area. the physician prescribes atropine sulfate (Atropisol). Placing the client in Trendelenburg’s position D. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension). Assessing the left leg B. two drops of 0.5% solution in the right eye twice daily.resulting from acute iris inflammation (iritis). Parasympathomimetic agent B. and polymyxin B sulfate (Neosporin Ophthalmic). Emergency medical technicians transport a 27-year-old iron worker to the emergency department. “He fell from a two- story building. As part of the client’s therapeutic regimen. Atropine sulfate belongs to which drug classification? A. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag. 0. Cholinergic blocker 10.” Which intervention by the nurse has the highest priority? A. Sympatholytic agent C. An auto mechanic accidentally has battery acid splashed in his eyes. He has a compound fracture of his left femur and he’s comatose. and then take him to the emergency department of a nearby hospital. Paresthesia in the dermatomes near the wounds C. Inhibiting the action of carbonic anhydrase.D. A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. After an eye examination. 0. Increasing the exudative reaction of ocular tissue. B. Temperature of 99. Dexamethasoneexerts its therapeutic effect by: A.both eyes every 3 hours. C. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris. More back pain than the first postoperative day B.25% into the right eye daily. Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. D. OU q. Instilling one drop of pilocarpine 0. the nurse should teach the client or a family member to administer the drug by: A. D. The physician prescribes Pilocarpine ophthalmic solution (Pilocar).3° C) 13. a male client is diagnosed with open- angle glaucoma. Based on this prescription. Decreasing leukocyte infiltration at the site of ocular inflammation. Urine retention or incontinence D.25% into the left eye four times daily. 14. 12. Which of the following findings should the nurse consider abnormal? A. Which behavior indicates that the client accurately understands safety measures related to paralysis? .i. Instilling one drop of pilocarpine 0. Instilling one drop of pilocarpine 0.25% gtt i. Instilling one drop of pilocarpine 0.25% into both eyes daily. C.2° F (37.25% into both eyes four times daily. B. Intestinal obstruction D. 15. Blood dyscrasia C. the nurse should use which term? A. Which hospital room would be the best choice for this client? A. The client uses a mirror to inspect the skin. prescribing pyridostigmine (Mestinon). age 22. Ataxic B. every 3 hours. B. The client repositions only after being reminded to do so. To assess gait.O. A semi private room with a 32-year-old client who has viral meningitis D. Before administering this anticholinesterase agent. D. A male client in the emergency department has a suspected neurologic disorder. the client’s feet make a half circle.A. To document the client’s gait. 60 mg P. Spinal cord injury . is admitted with bacterial meningitis. with each step. Helicopod D. A client. The client hangs the left arm over the side of the wheelchair. Which preexisting condition would contraindicate the use of pyridostigmine? A. C. the nurse reviews the client’s history. A two-bed room with a client who previously had bacterial meningitis 17. A physician diagnoses a client with myasthenia gravis. Dystrophic C. the nurse asks the client to take a few steps. A private room down the hall from the nurses’ station B. Ulcerative colitis B. The client leaves the side rails down. An isolation room three doors from the nurses’ station C. Steppage 16. ” C. A female client is admitted to the facility for investigation of balance and coordination problems. the nurse expects to note: A. including possible Ménière’s disease. blurred vision. and nystagmus C. “Don’t fly in an airplane. “Lie in bed with your head elevated. climb to high altitudes. Excessive tearing B. “Try to ambulate independently after about 24 hours. and hearing loss. Vertigo. B. “Shampoo your hair every day for ten (10) days to help prevent ear infection. D. Systemic absorption . or expose yourself to loud sounds for 30 days. and fever. Urine retention C.” B. When assessing this client. Slurred speech 21. Vertigo. Muscle weakness D. Vertigo. pain. tinnitus. 19. Vertigo. Which adverse reaction is most common? A. make sudden movements. Nurse Marty is monitoring a client for adverse reactions to dantrolene(Dantrium). and hearing impairment.” D.” 20. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. and refrain from blowing your nose for 24 hours. the nurse should provide which client instruction? A. The nurse is monitoring a male client for adverse reactions to atropinesulfate (Atropine Care) eyedrops.18. After the stapedectomy. vomiting. His physician prescribes diazepam (Valium).of atropine sulfate through the conjunctiva can cause which adverse reaction? A. Ineffective breathing pattern C. Impaired physical mobility B.O. continuous muscle spasms. Increased salivation C. In the intensive care unit. C. the nurse should assign the highest priority to which nursing diagnosis? A. treatment of spasticity associated with spinal cord lesions. A male client has a history of painful. Self-care deficit: Dressing/grooming 23. When planning this client’s care. long-term treatment of epilepsy. Apnea 22. two (2) mg P. twice daily. In addition to being used to relieve painful muscle spasms. Disturbed sensory perception (tactile) D. A female client who was found unconscious at home is brought to the hospital by a rescue squaD. 24. B. A male client is admitted with a cervical spine injury sustained during a diving accident. Tachycardia B. He has taken several skeletal muscle relaxants without experiencing relief. postoperative pain management of laminectomy clients. Hypotension D. Diazepam also is recommended for: A. the nurse checks the client’s oculocephalic (doll’s eye) response by: . postoperative pain management of diskectomy clients D. B. B. Cones. C. A female client who was trapped inside a car for hours after a head- on collision is rushed to the emergency department with multiple injuries. A male client is color blind. Introducing ice water into the external auditory canal. Medulla . Aqueous humor. Rods. C. The nurse understands that this client has a problem with: A. Diencephalon B. Touching the cornea with a wisp of cotton. the client responds to painful stimuli with decerebrate posturing. Shining a bright light into the pupil. The client may be less sensitive to the effects of a neuromuscular blocking agent. Lens. D. Pancuronium shouldn’t be used. D. Pancuronium and succinylcholine both require cautious administration. C. Turning the client’s head suddenly while holding the eyelids open. pancuronium may be used in a lower dosage. B. Succinylcholine shouldn’t be used. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? A. D. succinylcholine may be used in a lower dosage. While reviewing a client’s chart. 25.A. This finding indicates damage to which part of the brain? A. 27. During the neurologic examination. 26. the nurse notices that the female client has myasthenia gravis. . Tremors at rest D. Sit with the client for a few minutes. To determine when the client is ready for a liquid diet.C. C. Midbrain D. the nurse assesses the client’s swallowing ability once each shift. The nurse is caring for a male client diagnosed with a cerebral aneurysmwho reports a severe headache. Cranial nerves III and V. Call the physician immediately. D. Which action should the nurse perform? A. Administer an analgesic. This assessment evaluates: A. During recovery from a cerebrovascular accident (CVA). Cortex 28. to help prevent aspiration. Inform the nurse manager. B. Cranial nerves VI and VIII. C. Absent deep tendon reflexes C. B. a female client is given nothing by mouth. Cranial nerves I and II. Vision changes B. Cranial nerves IX and X. Which of the following symptoms would the nurse expect to find? A. Flaccid muscles 29. 30. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. D. Rest in an air-conditioned room. Place a tongue blade in the client’s mouth. and iron deficiency anemia. Her history reveals bronchial asthma. B. A male client is having tonic-clonic seizures. the nurse should tell the client to: A. Avoid naps during the day. D. Which history finding is a risk factor for CVA? A. The nurse is teaching a female client with multiple sclerosis.1. When the client asks the nurse about the paralysis. Restrain the client’s arms and legs. Take measures to prevent injury. Caucasian race B. B. D. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). exogenous obesity. C. how should the nurse respond? . What should the nurse do first? A. Take a hot bath. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. Female sex C. 4. Obesity D. When teaching the client how to reduce fatigue. C. Elevate the head of the bed. 3. Bronchial asthma 2. Increase the dose of muscle relaxants. Place a cap on the client’s head. The nurse must log roll a male client following a: A. B. “You’ll first regain use of your legs and then your arms.A. Immobilize the neck before the client is moved onto a stretcher. you won’t have any sensory loss. 7.” C. A female client with a suspected brain tumor is scheduled for computed tomography (CT). Use the pointed end of the reflex hammer when striking the Achilles’ tendon. Cystectomy. Tap the tendon slowly and softly D. D. 6. Administer a sedative as ordered. C. The nurse is working on a surgical floor.” D. However. “It must be hard to accept the permanency of your paralysis. or shellfish. contrast dyes.” B. Thoracotomy. During a routine physical examination to assess a male client’s deep tendon reflexes. B. Determine whether the client is allergic to iodine. the nurse should make sure to: A. Hemorrhoidectomy. What should the nurse do when preparing the client for this test? A. Hold the reflex hammer tightly. B. Laminectomy. . C. C. D. “You’ll have to accept the fact that you’re permanently paralyzeD. but the paralysis caused by this disease is temporary.” 5. Support the joint where the tendon is being tested. “You may have difficulty believing this. Risk for injury 9. D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg 11.8. Powerlessness C. Ineffective denial D. Prevent respiratory alkalosis. “Sometimes I feel so frustrateD. Impaired verbal communication D. Which nursing diagnosis takes highest priority for this client’s plan of care? A. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Anxiety B. Risk for disuse syndrome 10. C. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse. Nurse Mary witnesses a neighbor’s husband sustain a fall from the roof of his house. Self-care deficient: Dressing/grooming C. Disturbed sensory perception (visual) B. I can’t do anything without help!” This comment best supports which nursing diagnosis? A. Lower arterial pH. Promote carbon dioxide elimination. Flexed position B. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method? A. For a male client with suspected increased intracranial pressure (ICP). a most appropriate respiratory goal is to: A. Head tilt-chin lift . B. pulled up and head bent down onto the chest. The nurse would plan to use which plan to use which of the following to test the client’s peripheral response to pain? A. Jaw-thrust maneuver D. Nail bed pressure C. Side-lying. The nurse would plan to place the client in which position? A. Sternal rub B. Side-lying. Heart failure C. Prone.C. Hypertension B. with the legs. A male client is having a lumbar puncture performed. The nurse is assessing the motor function of an unconscious male client. Prone. Modified head tilt-chin lift 12. with a pillow under the hip B. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client’s history of: A. in slight-Trendelenburg’s position D. Chronic obstructive pulmonary disorder 14. with a pillow under the abdomen C. Which of the following positions would the nurse avoid? . Prosthetic valve replacement D. Pressure on the orbital rim D. 15. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse is positioning the female client with increased intracranial pressure. Squeezing of the sternocleidomastoid muscle 13. if possible. A female client has clear fluid leaking from the nose following a basilar skull fracture. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. Strict adherence to a bowel retraining program B. Is grossly bloody in appearance and has a pH of 6 C. Loosening restrictive clothing B. Limiting bladder catheterization to once every 12 hours 18. Separates into concentric rings and test positive of glucose 17. Head midline B. Removing the pillow and raising padded side rails D. Head of bed elevated 30 to 45 degrees 16. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Neck in neutral position D. with the head flexed forward . The nurse is caring for the male client who begins to experience seizureactivity while in beD. The nurse assesses that this is cerebrospinal fluid if the fluid: A. Restraining the client’s limbs C. Keeping the linen wrinkle-free under the client C. Preventing unnecessary pressure on the lower limbs D. Clumps together on the dressing and has a pH of 7 D. Positioning the client to side.A. Head turned to the side C. Is clear and tests negative for glucose B. Which of the following actions by the nurse would be contraindicated? A. The client has weakness on the right side of the body. The client has complete bilateral paralysis of the arms and legs. C. Gets angry with family if they interrupt a task B.19. The client has lost the ability to move the right arm but can walk independently. Consistently uses adaptive equipment in dressing self 22. The client with a brain attack (stroke) has residual dysphagia. Thickening liquids to the consistency of oatmeal C. 20. The nurse is assigned to care for a female client with complete right-sided hemiparesis. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? . B. The nurse assesses that the client is adapting most successfully if the client: A. Giving the client thin liquids B. the nurse avoids doing which of the following? A. The client has lost the ability to move the right arm but can walk independently. The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse plans care knowing that this condition: A. Placing food on the unaffected side of the mouth D. D. When a diet order is initiated. including the face and tongue. Allowing plenty of time for chewing and swallowing 21. Experiences bouts of depression and irritability C. Has difficulty with using modified feeding utensils D. The nurse tells the client that this is most effectively done by: A. Taking excess medication C. but possibly includes ischemia.A. Primary genetic in origin. Speaking to the client at a slower rate B. Primarily genetic in origin. viral infection. Doing muscle-strengthening exercises C. well-balanced meals B. Getting too little exercise B. The nurse would assess whether the client has precipitating factors such as: A. Unknown. Allowing plenty of time for the client to respond C. or an autoimmune problem B. Omitting doses of medication D. Completing the sentences that the client cannot finish D. The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. A female client has experienced an episode of myasthenic crisis. Taking medications on time to maintain therapeutic blood levels 25. A male client with Bell’s Palsy asks the nurse what has caused this problem. but possibly includes long-term tissue malnutrition and cellular hypoxia C. The nurse’s response is based on an understanding that the cause is: A. Looking directly at the client during attempts at speech 23. Doing all chores early in the day while less fatigued D. Increasing intake of fatty foods 24. Eating large. triggered by exposure to neurotoxins . Unknown. triggered by exposure to meningitis D. Providing information. Respiratory or gastrointestinal infection during the previous month. A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Exposure to cold and drafts B. the nurse would plan to do which of the following to ensure client to ensure client safety? . Specific to this impairment. Giving client full control over care decisions and restricting visitors B. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? A. Wrinkle the forehead. Back injury or trauma to the spinal cord D. Meningitis during the last five (5 years C. giving positive feedback and encouraging relaxation D. and whistle 27. reducing distractions and limiting visitors 29. The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing denervation. blow out the cheeks. Providing positive feedback and encouraging active range of motion C. A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. 28. Providing intravenously administered sedatives. Perform facial exercises D. The nurse determines that the client needs additional information if the client states that he or she will: A. Massage the face with a gentle upward motion C. The nurse inquires during the nursing admission interview if the client has a history of: A. Seizures or trauma to the brain B. A male client has an impairment of cranial nerve II.26. Check the temperature of the food on the delivery tray. and time B. Speak loudly to the client B. Affect is flat. D. Demonstrate inability to add and subtract. Cannot recall what was eaten for breakfast today D. Specific to this type of deficit. Provide a clear path for ambulation without obstacles 30. the nurse would document which of the following information related to the client’s behavior.A. with periods of emotional lability C. A. Test the temperature of the shower water C. A female client has a neurological deficit involving the limbic system. Is disoriented to person. does not know who is the president . place.