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Kaplan Neurology A

Terms in this set (30)

The nurse provides care for a newly admitted client diagnosed with a head injury. The nurse notes the client has clear nasal drainage. Which action does the nurse take first?
Checks the nasal drainage for glucose.
A client is admitted to the hospital with a diagnosis of myasthenia gravis. When caring for this client, the nurse gives priority to which nursing goal?
Maintain respiratory function.
The nurse in the emergency department admits clients from a multi-car accident. Which client does the nurse attend to first?
The client with clear fluid drainage from the right ear.
A client diagnosed with Parkinson disease has tremors of both upper arms. The nurse observes that the tremors disappear as the client unbuttons the shirt. Which statement indicates the most accurate understanding of the tremors?
Tremors decrease in severity when attention is diverted by activity.
The nurse discovers a client diagnosed with Meniere disease leaning over the sink in the room and clutching it with both hands. After determining the client is having an acute attack, which action does the nurse take first?
Helps the client back to bed and places a pillow on either side of the client's head.
The nurse understands which cranial nerve is affected in tic douloureux?
Trigeminal.
A client is scheduled for an electroencephalogram (EEG). The nurse instructs the client to omit which food from the diet before the test?
Hot chocolate.
Which nursing goal is most realistic and appropriate in planning care for a client diagnosed with Parkinson disease?
Maintain optimal function within the client's limitations.
Which clinical manifestation does the nurse anticipate when caring for a client with a history of multiple sclerosis? (Select all that apply.)
Urinary retention.
Hyperreflexia of the extremities.
Ataxia.
Decreased concentration.
The nurse in the outpatient clinic assesses a client diagnosed with trigeminal neuralgia. The nurse intervenes if the client makes which statement?
"I drink hot coffee with breakfast and after dinner."
The nurse provides care for a client diagnosed with Meniere disease. The nurse expects the client to exhibit which symptoms?
Vertigo, hearing loss, tinnitus.
A client is diagnosed with tonic-clonic seizures. The nurse tries to identify the client's aura. Which statement accurately describes an aura?
Unusual sensations prior to the seizure.
An older adult client is in a long-term care facility. The client says. "I know my children visited me today, but they deny it. What's going on? I'm so mixed-up." The nurse suspects this is due to sensory alternations. Which action by the nurse is best?
Encourage the client to discuss the "mixed-up" feelings.
The nurse provides care for a client admitted to the emergency department following an automobile accident. The client reports dizziness, and the health care provider suspects a head injury. The nurse intervenes if which activity is observed?
The client is placed in the Trendelenburg position.
The nurse provides care for a client scheduled for an electroencephalogram (EEG). To prepare the client for the test, it is most important for the nurse make which statement?
"The procedure is not painful but you must lie still."
An older adult client is admitted with a diagnosis of acute pulmonary edema. Which is the best intervention for the nurse to include to prevent sensory deprivation?
Assess the family support system.
The nurse provides care for a client admitted to the medical/surgical unit diagnosed with a stroke. The nurse plans care to prevent the client from experiencing sensory overload. The nurse determines which plan is most effective?
The nurse obtains vital signs and assists the client with morning care in one visit.
The nurse provides care for a client diagnosed with a closed head injury and increased intracranial pressure. Which action by the nurse is best?
Instruct client to exhale when turning or moving in bed.
The nurse provides care for a client diagnosed with a spinal cord injury at the level of T-3. The client reports a pounding headache and nasal congestion. The nurse notes the client has profuse sweating form the forehead and piloerection. Which action does the nurse take first?
Checks the indwelling urinary catheter and tubing for kinks.
The nurse provides care for a client with a diagnosis of traumatic brain injury. The client has a score of 7 on the Glascow Coma Scale. The nurse identifies it is important to give eye care to this client for which reason?
To prevent corneal irritation.
The nurse provides education to the family member of a client diagnosed with Parkinson disease. Which statement by the family member reflects a need for further education?
"I will buy lots of broth and soup for my parent."
A client is diagnosed with a possible stroke. The client has a history of poorly controlled hypertension. The client takes antihypertensive medication and hormone replacement therapy. The client appears overweight and admits to mostly watching television or working on the computer all day. The nurse identifies which risk factor as most significant for development of a stroke for this client?
Hypertension.
The nurse instructs a client diagnosed with Bell palsy. It is most important for the nurse to make which statement about nighttime care?
"Apply an eye shield over the affected eye."
The nurse provides care for a client suspected of having a seizure disorder. The client tells the nurse, "I smelled oranges today and there wasn't one on my tray." Which response by the nurse is best?
Have you experienced this sensation before?
The nurse in the outpatient clinic provides care for a client diagnosed with Bell Palsy. Which action does the nurse take first?
Assesses the client's pain experience.
While the nurse ambulates the client to the bathroom, the client begins to have a seizure. Which action does the nurse take first?
Eases the client to the floor.
The nurse provides care for a client diagnosed with right-sided hemiplegia due to a stroke. The nurse observes the client has an inability to eat without total assistance. Which intervention is most appropriate to improve the client's nutrition?
Provide a pureed diet.
A client has a diagnosis of meningitis. The nurse assesses the client. The nurse notes that when the client flexes the head, the client also flexes the hip and knee. Which nursing action is best?
Immediately report this finding to the health care provider.
A client is diagnosed with typical absence seizures. It is most important for the nurse to take which action?
Monitor the client for brief interruptions of consciousness.
The nurse identifies which manifestation as most characteristic of myasthenia gravis?
Tiredness with slight exertion.
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