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neuro

Terms in this set (11)

A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client?
a. Help the client identify each medication by its color.
b. Provide written materials with large print size.
c. Sit on the clients right side and speak into the right ear.
d. Allow the client to use a white board to ask questions.
ANS: C
The temporal lobe contains the auditory center for sound interpretation. The clients hearing will be impaired in the left ear. The nurse should sit on the clients right side and speak into the right ear. The other interventions do not address the clients left temporal lobe damage.
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this clients teaching?
a. Place soft rugs in your bathroom to decrease pain in your feet.
b. Bathe in warm water to increase your circulation.
c. Look at the placement of your feet when walking.
d. Walk barefoot to decrease pressure ulcers from your shoes.
ANS: C
Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client should wear sturdy shoes for ambulation.
A nurse assesses a client recovering from a cerebral angiography via the clients right femoral artery. Which assessment should the nurse complete?
a. Palpate bilateral lower extremity pulses.
b. Obtain orthostatic blood pressure readings.
c. Perform a funduscopic examination.
d. Assess the gag reflex prior to eating.
ANS: A
Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings cannot be performed. The funduscopic examination would not be affected by cerebral angiography. The client is given analgesics but not conscious sedation; therefore, the clients gag reflex would not be compromised.
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test?
a. Have you had a recent blood transfusion?
b. Do you have allergies to iodine or shellfish?
c. Are you taking any cardiac medications?
d. Do you currently use oral contraceptives?
ANS: B
Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the dye used in the procedure. In some cases, the client may need to be medicated with antihistamines or steroids before the test is given. A recent blood transfusion or current use of cardiac medications or oral contraceptives would not affect the angiography.
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure?
a. Creatine phosphokinase (CPK) of 100 IU/L
b. Atrioventricular graft
c. Blood urea nitrogen (BUN) of 50 mg/dL
d. Internal insulin pump
ANS: D
Metal devices such as internal pumps, pacemakers, and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An atrioventricular graft does not contain any metal. CPK and BUN levels have no impact on an MRI procedure.
A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this clients plan of care?
a. Provide a call button that requires only minimal pressure to activate.
b. Write the date on the clients white board to promote orientation.
c. Ensure that the path to the bathroom is free from equipment.
d. Encourage the client to season food to stimulate nutritional intake.
ANS: C
Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning food do not address the clients impaired sensory perception.
After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the clients understanding. Which client statement indicates a correct understanding of the teaching?
a. I must increase my fluids because of the dye used for the MRI.
b. My urine will be radioactive so I should not share a bathroom.
c. I can return to my usual activities immediately after the MRI.
d. My gag reflex will be tested before I can eat or drink anything.
ANS: C
No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the clients urine would not be radioactive. The procedure does not impact the clients gag reflex.
A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider?
a. Shingles on the clients back
b. Client is claustrophobic
c. Absence of intravenous access
d. Paroxysmal nocturnal dyspnea
ANS: A
An LP should not be performed if the client has a skin infection at or near the puncture site because of the risk of infection. A nurse would want to notify the health care provider if shingles were identified on the clients back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the clients needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP can be performed.
A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this procedure should alert the nurse to urgently contact the health care provider?
a. Weak pedal pulses
b. Nausea and vomiting
c. Increased thirst
d. Hives on the chest
ANS: B
The nurse should immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.
A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)
a. Ensure that an informed consent is present.
b. Ask the client about any allergies.
c. Evaluate the clients renal function.
d. Auscultate bilateral breath sounds.
e. Assess hematocrit and hemoglobin levels.
ANS: A, B, C
A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies to iodine or shellfish. The clients kidney function should also be evaluated to determine if it is safe to administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the clients breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence the clients safety during the procedure.
A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)
a. Long-term memory loss
b. Slower processing time
c. Increased sensory perception
d. Decreased risk for infection
e. Change in sleep patterns
ANS: B, E
Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.
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