Neurological Problems

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client’s peripheral response to pain?

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising?

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.

1. Keeping the linens wrinkle-free under the client
2. Preventing unnecessary pressure on the lower limbs
3. Limiting bladder catheterization to once every 12 hours
4. Turning and repositioning the client at least every 2 hours
5. Ensuring that the client has a bowel movement at least once a week

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.

1. Loosening restrictive clothing.
2. Restraining the client’s limbs.
3. Removing the pillow and raising padded side rails.
4. Positioning the client to the side, if possible, with the head flexed forward.
5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

1. The client is aphasic.
2. The client has weakness on the right side of the body.
3. The client has complete bilateral paralysis of the arms and
4. The client has weakness on the right side of the face and tongue.
5. The client has lost the ability to move the right arm but is able to walk independently.
6. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?

The nurse is instructing a client with Parkinson’s disease about preventing falls. Which client statement reflects a need for further teaching?

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness?

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client’s safety? Select all that apply.

1. Padding the side rails of the bed.
2. Placing an airway at the bedside.
3. Placing the bed in the high position.
4. Putting a padded tongue blade at the head of the bed.
5. Placing oxygen and suction equipment at the bedside.
6. Flushing the intravenous catheter to ensure that the site is patent.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions?

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse should bring which most essential items into the client’s room?