Neurology NCLEX SET 1
1. The nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which statement made by the client indicates an understanding of the instructions?
2. The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed?
3. The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures.
4. The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially?
5. Which intervention should be implemented for the older client with presbycusis who has a hearing loss?
6. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply.
7. The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?
8. The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record?
9. The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment?
10. A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client?
11. A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action?
12. A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure?
13. The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action?
14. The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique?
15. The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication?
16. A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed?
17. The nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which?
18. A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist in controlling the vertigo?
19. The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client?
20. A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?
21. Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?
22. The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take?
23. In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops knowing that the purpose of this medication is which?
24. The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which?
25. The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take?
26. The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question?
27. The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply.
28. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint?
29. Pilocarpine hydrochloride (IsoptoCarpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?
30. A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which?
31. A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply.
32. The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?
33. The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse?
34. The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity?
35. The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?
36. The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time?
37. The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom?
38. The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively?
39. The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client?
40. The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?
41. The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted?
42. The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?
43. The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take?
44. The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply.
45. The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room?
46. The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client?
47. The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which documented characteristic regarding the results of the otoscopic examination?
48. A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which is the most common client complaint associated with a disorder involving the inner ear?
49. The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse should expect to note documentation of which early symptom of this disorder?
50. The nurse provides discharge instructions to the client who was hospitalized for an acute attack of Ménière's disease. Which statement made by the client indicates a need for further teaching?
51. The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching?
52. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse reviews the test and determines that the intraocular pressure is normal if which result is noted?
53. The nurse is assisting in developing a plan of care for the client scheduled for cataract surgery. The nurse makes suggestions regarding the plan, knowing that which problem is specifically associated with this type of surgery?
54. The nurse is reviewing the health record of a client diagnosed with a cataract. The initial sign/symptom that the nurse should expect to note in the early stages of cataract formation is which?
55. The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position?
56. During the early postoperative stage, the cataract extraction client complains of nausea and severe eye pain over the operative site. Which action should the nurse implement?
57. The nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding should be an early indication that the level of consciousness (LOC) is deteriorating?
58. The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions?
59. The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated?
60. The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client?
61. The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which?
62. A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor?
63. A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease?
64. The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement?
65. A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety?
66. The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching?
67. The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume?
68. The nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care based on which expected outcome?
69. A clinic nurse notes that following several eye examinations the health care provider has documented a diagnosis of legal blindness in the client's chart. Which should the nurse expect to note documented as the result of the Snellen chart test?
70. The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops should the nurse expect to be prescribed?
71. A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions?
72. A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client?
73. A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate?
74. The nurse should check for vision loss in a client with which condition?
75. The nurse is assisting the health care provider with performing a Weber tuning fork test on a client. What does this test assess for?
76. The nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which statement by the client indicates an understanding of the instructions?
77. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery?
78. The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury?
79. The nurse is assigned to care for a client with a diagnosis of Ménière's disease. Which part of the ear is affected with Ménière's disease?
80. Surgery has been recommended for the client with otosclerosis. The client tells the nurse that she would prefer not to have surgery and asks the nurse about alternative methods to improve hearing. The nurse should make which appropriate response to the client?
81. The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response should the nurse make to the client regarding the hearing loss?
82. The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription noted on the client's chart should the nurse question?
83. A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further teaching?
84. The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which should be included on the list of instructions prepared for the client?
85. A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction should the nurse provide to the client?
86. A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?
87. The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client?
88. A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration?
89. The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems?
90. A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which action by the family?
91. The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure?
92. A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which finding noted in the client history indicates that the client may be ineligible for this diagnostic procedure?
93. A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse should provide reassurance to the client about the procedure?
94. The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client?
95. The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure?
96. The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which complication of hypothermia blanket use?
97. The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain?
98. A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement?
99. The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation?
100. The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply.
101. The nurse is preparing to give the postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." The nurse should formulate a response based on which understanding of codeine?
102. The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further teaching?
103. The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance?
104. A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse?
105. A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this?
106. A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity?
107. A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will do which?
108. The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury?
109. The nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to research seizures and related documentation points if the student states which assessment is important?
110. The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measure should the nurse avoid in planning for the client's safety?
111. The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client makes which comment?
112. A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the should nurse avoid which action?
113. The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client?
114. A client receives a dose of edrophonium (Enlon). The client shows improvement in muscle strength for a period of time following the injection. The nurse should interpret this finding as indicative of which disease process?
115. A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client? Select all that apply.
116. The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity?
117. The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statements?
118. A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client where?
119. The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity?
120. An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which is consistent with normal findings?
121. The nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the health care provider and reports that the client is exhibiting which?
122. An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 am. The nurse should first determine which about the client?
123. An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation?
124. A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which?
125. The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information?
126. The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should perform which?
127. The nurse overhears the term sundowning used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. Of which diagnosis is sundowning a symptom?
128. The nurse has reinforced discharge instructions to the client who has had ocular surgery of the right eye. The nurse determines that the client needs further teaching if the client states which?
129. A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement?
130. A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observation?
131. An adult client with suspected meningitis has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis of a bacterial infection. The nurse checks for which value indicating a bacterial infection of the CSF?
132. A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder?
133. The nurse is preparing to reinforce instructions to a client with glaucoma regarding the prescribed treatment measures for the disorder. The nurse prepares the instructions based on which treatment goal?
134. The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions should the nurse reinforce to the client?
135. The nurse reinforces instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further teaching?
136. A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestation associated with this disorder should the nurse expect to be documented in the client's record?
137. Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching?
138. A client is brought to the ambulatory care department by the spouse one day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement?
139. The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching?
140. The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which symptom?
141. The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction should the nurse include in the teaching plan for the client?
142. The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse should take which action?
143. A client arrives at the emergency department after experiencing a traumatic blow to the eye and a hyphema is diagnosed. In which position should the nurse place the client?
144. A client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action?
145. A client arrives in the emergency department with an eye injury caused by metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse plan to assist with first?
146. A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action?
147. The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan?
148. The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching?
149. The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which action?
150. The nurse is monitoring a client with a head injury and notes that the client is assuming the posture shown in the figure. What is the client exhibiting that would require the nurse to notify the registered nurse immediately? Refer to the figure.
151. The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look?
152. The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride (IsoptoCarpine)? Select all that apply.
153. The nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle crash. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation?
154. The nurse is caring for a client diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy?
155. The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data should focus on which characteristic of this disease?
156. The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply.
157. The nurse is ambulating a client with a known seizure disorder. The client says, "I'm seeing those flashing lights again," then loses consciousness and develops a clonic-tonic seizure. Which would be the nurse's initial action?
158. The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement?
159. The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? Select all that apply.
160. A client arrives at the emergency department following a blow to the eye from a softball. Which intervention should be implemented by the nurse initially?
161. While at home, the nurse receives a telephone call from a neighbor, who reports that while accidentally breaking a mirror, a piece of glass flew into her eye. Which is the appropriate initial nursing action after observing that the large glass shard is protruding from the neighbor's eye?
162. A client arrives at the emergency department following an eye injury in which an acid used to clean the brick on the fireplace splashed into the eye. Which question should the nurse ask initially?
163. The nurse is caring for a client following enucleation. Which postsurgical observation requires immediate attention by the nurse?
164. Which instruction is appropriate for the nurse to provide to a client who reports via telephone that he is certain an insect has flown into his ear because he can hear it "buzzing"?
165. Which statement by the nurse indicates an understanding of the diagnosis of presbycusis?
166. The nurse determines that the client diagnosed with Ménière's disease understands the reinforced dietary instructions when the client states that which food will be avoided in the diet?
167. The nurse is assisting in developing a plan of care for a client following the surgical removal of an acoustic neuroma. Which assessment will be included in the plan of care for this specific intervention?
168. A client is being discharged from the ambulatory care unit following cataract removal. Which instruction from the discharge teaching plan should the nurse reinforce?
169. The nurse is reinforcing instructions to a client following a cataract extraction on the right eye. Which statement by the client indicates a need for further teaching?
170. When the nurse documents the results of a Snellen vision test as 20/80 vision, the client asks the nurse to describe what these numbers mean. Which statement is the appropriate response?
171. Which information will the nurse reinforce to the client scheduled for a lumbar puncture?
172. The nurse is reinforcing instructions to a client taking divalproex sodium (Depakote). The nurse tells the client to return to the clinic for follow-up laboratory studies related to which test?
173. Which data collection finding supports the possible diagnosis of Bell's palsy?
174. The nurse reviews the health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription noted in the client's record should the nurse question?
175. A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which action to determine whether the client is ready to begin sitting up?
176. A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client?
177. A client with myasthenia gravis is experiencing prolonged periods of weakness. The health care provider prescribes a test dose of edrophonium (Enlon) and the client becomes weaker. The nurse interprets this outcome as indicative of which result?
178. The nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). The nurse understands that the client should be asked to perform which action?
179. The nurse is assisting to perform a Romberg test on a client being seen in the clinic. The nurse performs this test to make which determination?
180. A perforated eardrum is suspected in a client who was hit in the ear with a basketball. Which documented observation concerning an otoscopic examination supports this suspicion?
181. The nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to check which client ability?
182. The nurse in a health care clinic is assisting to test the client for accommodation. The nurse should ask the client to perform which initial action?
183. The nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). Which initial sign/symptom of this disorder supports this diagnosis?
184. The nurse is assisting in caring for a client with a supratentorial lesion. The nurse monitors which criterion as the critical index of central nervous system (CNS) dysfunction?
185. The nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which indicates an early sign of increased ICP?
186. Acetazolamide is prescribed for a client with a diagnosis of a supratentorial lesion. The nurse monitors the client for effectiveness of this medication, knowing which is its primary action?
187. Which sign/symptom is observed in the clonic phase of a seizure?
188. The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply.
189. The nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. The nurse assists in developing a plan of care, knowing that which is a characteristic of early Alzheimer's disease?
190. The clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. The nurse notes that the client is prescribed selegiline hydrochloride (Eldepryl). The nurse understands that this medication is prescribed for which diagnosis?
191. The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. Which documented early symptom supports this diagnosis?
192. The nurse is assisting in caring for a client with a suspected diagnosis of meningitis. The nurse reinforces to the client information regarding which diagnostic test that is commonly used to confirm this diagnosis?
193. The nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. Which diagnostic test should be prescribed to confirm this diagnosis?
194. The nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin (Ditropan). The nurse evaluates the effectiveness of the medication by asking the client which question?
195. The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. Which sign/symptom is considered a primary symptom of this syndrome?
196. A thymectomy via a median sternotomy approach is performed on a client with a diagnosis of myasthenia gravis. The nurse has assisted in developing a plan of care for the client and includes which nursing action in the plan?
197. The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the client is alert and oriented to time and place. Based on these findings, the nurse makes which determination?
198. The nurse is preparing to care for a client with a diagnosis of brain attack (stroke). The nurse notes in the client's record that the client has anosognosia. The nurse plans care, knowing which is a characteristic of anosognosia?
199. The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization?
200. The nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, which action does the nurse plan?
201. The nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. Which is the initial nursing action?
202. Prescriptive eyeglasses are prescribed for a client with bilateral aphakia. When reinforcing teaching instructions regarding the eyeglasses, the nurse determines the need for further teaching when the client makes which statement?
203. The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching?
204. The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client?
205. A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action?
206. A client arrives at the emergency department for treatment of an injury to the eye after being hit by a baseball bat. On data collection, the nurse notes that the eye is bleeding. Which nursing action is appropriate?
207. A client arrives in the emergency department following an eye injury from a chemical solution. Which is the initial nursing action?
208. The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart should the nurse question?
209. The nurse has reinforced instructions to a client following a right keratoplasty. Which statement by the client indicates a need for further teaching?
210. The nurse caring for a client in the postoperative period following an enucleation notes bloody staining on the surgical eye dressing. Which is the appropriate nursing action?
211. A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures?
212. The nurse is reinforcing home care instructions to a client who has a hordeolum (sty) of the right eye. Which statement by the client indicates an understanding of the instructions?
213. The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse should document the findings of this test as indicative of which result?
214. The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the client complains of vertigo. The nurse documents the findings of this test as indicative of which result?
215. The nurse is assisting a health care provider in performing a caloric test on a client. Following instillation of warm water into the ear, the nurse notes that nystagmus does not occur. The nurse should document the findings of this test as indicative of which result?
216. A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test?
217. A nursing instructor asks a student about cochlear implants. The student understands that which clients are candidates for such a procedure? Select all that apply.
218. A female client with myasthenia gravis comes to the health care provider's office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. Which is the appropriate nursing response?
219. The nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem? Select all that apply.
220. The nurse is reinforcing discharge instructions to a client going home after same-day eye surgery. During the postoperative period, the nurse stresses that the client may safely perform which activity?
221. The nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further teaching?
222. A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which?
223. A client diagnosed with primary open-angle glaucoma has been prescribed pilocarpine ophthalmic drops. When the client asks the nurse how this medication lowers intraocular pressure, which information does the nurse tell the client?
224. The nurse interprets that a client diagnosed with glaucoma needs information about the expected effects of this condition when the client makes which statement?
225. The nurse is preparing to instill an otic solution into the adult client's right ear. The nurse should include which action while performing this procedure? Select all that apply.
226. A client has a diagnosis of presbycusis. The nurse interprets that which behavior indicates that the client has successfully adapted to this disorder?
227. Immediately following cataract repair, the client's affected conjunctiva and eyelids are edematous. Which statement by the nurse accurately characterizes these findings for the client?
228. A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client?
229. A client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to engage in which activity to prevent barotrauma during takeoff and landing? Select all that apply.
230. A client has had same-day surgery to insert a ventilating tube in the tympanic membrane. The nurse reinforces to the client to be sure to perform which action until the postoperative assessment by the health care provider?
231. An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history?
232. A client is recovering at home after suffering a brain attack (stroke) 2 weeks ago. A home caregiver tells the home health nurse that the client has some difficulty swallowing food and fluids. Which nursing action would be appropriate?
233. When reinforcing information to a client regarding how to appropriately care for a new hearing aid, the nurse should provide the client with which instruction?
234. A client susceptible to motion sickness asks the nurse about the use of medication to prevent an occurrence. The nurse plans to incorporate into the discussion that the medication works effectively if which guideline is followed?
235. The nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation?
236. A client has been diagnosed with open-angle glaucoma and asks the nurse to repeat the health care provider's explanation of the disorder. The nurse should offer the client which explanation?
237. The nurse is reinforcing education to a client who has just obtained a hearing aid about its use and maintenance. The nurse tells the client that it is helpful to follow which practice?
238. A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the health care provider to instill which acceptable solutions into the ear to remove the insect? Select all that apply.
239. The nurse is collecting neurological data on a poststroke adult client. Which technique should the nurse perform to adequately check proprioception?
240. After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated with which intervention?
241. The nurse is reinforcing discharge teaching to a client following right eye cataract surgery. The nurse determines that the client needs further teaching about ways to avoid strain on the operative eye when the client makes which statements? Select all that apply.
242. The nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.
243. A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem?
244. The nurse is assisting in checking for Tinel's sign in a client suspected of having carpal tunnel syndrome (CTS). Which technique should the nurse expect to be used to elicit this sign?
245. The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from the spinal shock?
246. The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that an early sign of rupture is which?
247. The nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign if noted in the client should the nurse report immediately?
248. The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which?
249. A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching?
250. The nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which intervention does the nurse document in the plan as the priority nursing intervention for this client?
251. The nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. Which statement by the client indicates the client understands the discharge instructions?
252. The nurse is collecting admission data on a client with Parkinson's disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which in the client's record?
253. A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which signs and symptoms? Select all that apply.
254. The nurse is reinforcing discharge instructions to a client following right eye cataract surgery about ways to avoid strain on the operative eye. The nurse determines that the client needs further teaching if the client makes which statement?
255. The nurse is caring for a client with acute otitis media. The nurse plans care knowing which treatment for this problem is likely to be included?
256. The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information?
257. The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply.
258. A client is suspected of having a diagnosis of Guillain-Barré syndrome (GBS). Which findings would support a diagnosis of Guillain-Barré syndrome? Select all that apply.
259. The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure should the nurse include in the plan of care?
260. The nurse is reinforcing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. Which instruction should the nurse give the client?
261. The nurse is reviewing the health care record of a client suspected of having mastoiditis. Which finding does the nurse expect to note if this disorder is present?
262. A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing instructor asks the student to describe the types of medication that will likely be prescribed for the client to treat the eye disorder. Which drug classification will facilitate the outflow of aqueous humor?
263. A nursing student is preparing to assist with an ear irrigation on an assigned client who has a buildup of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The student nurse should perform the procedure in which correct order? Arrange the actions in the order that they should be used. All options must be used.
264. A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma?
265. The nurse is observing an unlicensed assistive personnel (UAP) talk to a client who is hearing impaired. The nurse should intervene if which action is performed by the UAP during communication with the client?
266. A clinic nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching?
267. The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder?
268. The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. Which method is the best way for the nurse to explore issues with the client regarding these behaviors?
269. A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) protein is 750 mg/dL. The nurse analyzes these results as which?
270. A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication?
271. The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury?
272. A client with tetraplegia complains bitterly about the nurse's slow response to the call light and the rigidity of the therapy schedule. Which interpretation of this behavior should serve as a basis for planning nursing care?
273. A client with Parkinson's disease is developing dementia. Which action should the nurse plan to assist the client in maintaining self-care abilities?
274. The nurse is caring for a client that is comatose and notes in the client's chart that the client is exhibiting decerebrate posturing. The nurse understands that which definition describes decerebrate posturing?
275. A client recovering from a craniotomy complains of a "runny nose." Based on the interpretation of the client's complaint, which action should the nurse take?
