The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing. B. Restraining the client’s limbs. C. Removing the pillow and raising padded side rails. D. Positioning the client to… Read More »
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? A. Give the client a warming blanket. B. Administer low-dose barbiturate. C. Encourage the client to hyperventilate. D. Restrict fluids. Correct Answer: C. Encourage the client to hyperventilate. Normal… Read More »
A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety? A. Speak loudly to the client. B. Test the temperature of the shower water. C. Check the temperature of the… Read More »
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: A. The client has complete bilateral paralysis of the arms and legs. B. The client has weakness on the right side of the body, including the face and tongue. C.… Read More »
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupil D. Decrease in LOC Correct Answer: D. Decrease in LOC A decrease… Read More »
A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client’s behavior. A. Is disoriented to person, place, and time. B. Affect is flat, with periods of emotional lability. C. Cannot recall what… Read More »
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? A. Giving the client thin liquids. B. Thickening liquids to the consistency of oatmeal. C. Placing food on the unaffected side of the mouth. D. Allowing plenty… Read More »
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? A. Place her in a jacket restraint. B. Wrap her hands in soft “mitten” restraints. C. Tuck her arms and hands under the… Read More »
A client is admitted with a diagnosis of Sturge-Weber syndrome. Which of the following information would you expect to find in this client? A. It is a dysfunction of the trigeminal nerve causing a severe sharp pain in the nose, lips, gums, or across the cheeks. B. It is a non-progressive neurological disorder… Read More »
The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: A. Gets angry with family if they interrupt a task. B. Experiences bouts of depression and irritability. C. Has difficulty with… Read More »