Neurology NCLEX | VERIFIED SOLUTION

Neurology NCLEX | VERIFIED SOLUTION Neurology NCLEX 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? Answer: "I should not sleep on my right side." 2. The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed? Answer: Semi-Fowler's position 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. Answer: A 4. The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially? Answer: Stand in front of the client. 5. Which intervention should be implemented for the older client with presbycusis who has a hearing loss? Answer: Use low-pitched tones. 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. Answer: To avoid activities that require bending over To place an eye shield on the surgical eye at bedtime To contact the surgeon if a decrease in visual acuity occurs To take acetaminophen (Tylenol) for minor eye discomfort 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? Answer: Eye medications will need to be administered for the rest of your life. 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? Answer: A sense of a curtain falling across the field of vision 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? Answer: Complaints of a burst of black spots or floaters 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? Answer: On bed rest in a semi-Fowler's position 11. A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? Answer: Apply ice to the affected eye. 12. A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? Answer: Irrigating the eye with sterile normal saline 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? Answer: Report the finding to the registered nurse (RN). 14. The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique? Answer: Pulling the pinna up and back 15. The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication? Answer: Speak in a normal tone. 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? Answer: Instillation of mineral oil or diluted alcohol 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? Answer: A sensorineural hearing loss that occurs with aging 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? Answer: Avoid sudden head movements. 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? Answer: Low-sodium diet 20. A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? Answer: Cardiovascular disease 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? Answer: Monitoring blood pressure 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? Answer: Warm the irrigating solution to 98° F. 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? Answer: Dilate the pupil of the operative eye. 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? Answer: Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops. 25. The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take? Answer: Administer the eyedrop first, followed by the eye ointment. 26. The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? Answer: Atropine sulfate (Isopto Atropine) 27. The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply. Answer: Wash hands. Put on gloves. Place the drop in the conjunctival sac. Pull the lower lid down against the cheekbone. 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? Answer: Acetylsalicylic acid (aspirin) 29. Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? Answer: Atropine sulfate 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? Answer: "The medication causes the pupil to constrict and will lower the pressure in the eye." 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. Answer: Pad the bed's side rails. Place an airway at the bedside. Place oxygen equipment at the bedside. Place suction equipment at the bedside. 32. The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? Answer: Increasing temperature, decreasing pulse, decreasing respirations, increasing BP 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? Answer: Head turned to the side 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? Answer: Exhaling during repositioning 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? Answer: Separates into concentric rings and tests positive for glucose 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? Answer: The health care provider reviews the x-ray results. 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? Answer: Minor headache 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? Answer: Head of bed elevated 30 to 45 degrees, head and neck midline 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? Answer: Comparing the amount of prescribed weights with the amount in use 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? Answer: "I will drive only during the daytime." 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? Answer: Severe, throbbing headache 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? Answer: Limiting bladder catheterization to once every 12 hours 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? Answer: Raise the head of the bed and remove the noxious stimulus. 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. Answer: Face the client when talking. Speak slowly and maintain eye contact. Use gestures when talking to enhance words. Give the client directions using short phrases and simple terms. 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? Answer: Electrocardiographic monitoring electrodes and intubation tray 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? Answer: Smiling continuously during conversation 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? Answer: Red, dull, thick, and immobile tympanic membrane 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? Answer: Tinnitus 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? Answer: Ringing in the ears 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? Answer: "It is not necessary to restrict salt in my diet." 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? Answer: "I should turn the hearing aid off after removing it from my ear." 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? Answer: 15 mm Hg 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? Answer: Sensory perceptual alteration 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? Answer: Blurred vision 55. The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position? Answer: On the nonoperative side 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? Answer: Report the client's complaints. 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? Answer: Drowsiness 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? Answer: Maintaining the head of the bed at 15 degrees 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? Answer: Restrain the client's limbs. 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? Answer: Within the client's reach, on the left side 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? Answer: Remind the client to turn the head to scan the lost visual field. 62. A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor? Answer: Omitted doses of medication 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? Answer: Encourage and praise perseverance in exercising and performing ADL. 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? Answer: "I will try to eat my food either very warm or very cold." 65. A client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety? Answer: Provide a clear path for ambulation without obstacles. 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? Answer: "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye." 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? Answer: Sugar-free Jell-O 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? Answer: The surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac. 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? Answer: 20/200 vision 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? Answer: A mydriatic medication 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? Answer: "I will wear my eye shield at night and my glasses during the day." 72. A client with glaucoma asks the nurse if complete vision will return. The nurse should make which response to the client? Answer: "Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." 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? Answer: Placing an eye patch over the client's affected eye 74. The nurse should check for vision loss in a client with which condition? Answer: Diabetes mellitus 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? Answer: Hearing loss