The nurse is caring for a client and wants to assess the neurologic function. Which of the following will give the most information? A. level of consciousness B. doll’s eye’s reflex C. Babinski reflex D. reaction to painful stimuli
A. Yes! The most important and subtle changes are related to the client’s level of consciousness, verbal ability, orientation, and ability to move to command.
The client with an old C6 spinal cord injury complains of suddenly being too warm, with nasal congestion and a very red face. What is your next assessment? A. temperature B. blood pressure C. input and output for previous 8 hours D. bowel for impaction
B. Yes! This is autonomic dysreflexia and is usually associated with hypertension. Sit them up quickly
The nurse is caring for a client complaining of intense headaches with increasing pain for the past one month. A MRI is ordered. In reviewing the client’s information, which piece of information is of concern? A. client is allergic to shellfish B. client has a cardiac pacemaker C. client is a diabetic D. client has no IV access
B. Yes! IF a client with a cardiac pacemaker has an MRI the pacemaker is turned off and the client could die.
The nurse is discharging a client after a concussion. Which of the following should be reported? A. difficulty waking up B. headache (3/10 on the pain scale) C. bruising on knees and elbows D. achy feeling all over
A. Yes! This is change in consciousness
The client presents with fever, chills, positive Kernig and Brudinski as well as nucchal rigidity. What disorder is suspected here? A. flu B. cerebrovascular accident (CVA) C. meningitis D. cerebral arteritis
C. Yes! This is typical
The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracrainal hypertension? A. hypoventilation B. elevating the head of the bed C. hypernatremia D. quiet darkened environnent
A. Yes! Hypoventilation leads to vasodilation and increased intracranial pressure
The client is admitted with period of unobserved loss of consciousness and now has an EEG scheduled this am. Which of the following should the nurse implement? A. hold NPO and hold their medication B. hold sedatives, but allow client to have breakfast and give other, medicines C. administer meds but hold anticonvulsants D. give additional fluids and some caffeine prior to the test.
B. Yes. Prior to an EEG we want the client to eat so the blood sugar does not drop and they should take medications except sedatives prior to the EEG
What is an expected outcome for a client with increased intracrainal pressure receiving a stat dose of Mannitol®? A. increased oncotic shift of fluids B. improvement in glascow coma scale C. increase in amount of urine output D. lowering of intraocular pressure
C. Osmotic diuretics pull fluid from the tissues and cause diuresis through the kidneys so the client will have an increased urine output but the water came from the tissues
One week ago a client was involved in a motor vehicle crash (MVC)and was brought to the Emergency Department (ED). In the emergency department the client received two stitches to the forehead and was sent home. Today the client’s spouse notes the client “acts like he is drunk” and cannot control his right foot and arm. What does this scenario suggest? A. meningitis B. absence seizure C. subdural hematoma D. Meniere’s Disease
C. Yes! Subacute subdural hematoma. Head injury with slow venous bleed and the body does not have symptoms until compensation is exhausted.
The nurse is caring for a client with myasthenia gravis. What is an important teaching that is essential for this client’s care? A. sit up to eat and use the tongue thrust chin tuck B. rigorous monitoring of intake and output C. use of sweeping gaze when walking D. setting the alarm clock for medication times
Yes – medication must be taken on time. Too early can cause complication of weakness and too late can cause extreme weakness to point of paralysis. * Most important