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Exam (elaborations)

ATI neuro questions and answers 2023

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ATI neuro questiond and answers 2023 A nurse is providing discharge teaching to a family of a client who has a new diagnosis of a seizure disorder the nurse should instruct the clients family to take following actions first in the event of a seizure - protect the clients head A nurse is assessing a patient who has sustained a recent head injury which of the following findings should the nurse recognize as a manifestation of increase intracranial pressure - A widening of pulse pressure which is the difference between systolic and diastolic pressure it is a manifestation of increased intracranial pressure other manifestations include pulse changes, change in level of consciousness and nausea and vomiting A nurse is assessing a patient who is post op following a craniotomy and has a urine output of 600 mL per hour the nurse suspects the patient has manifestations of diabetes insipidus, which of the following lab values should the nurse plan to obtain to test for DI - Diabetes insipidus is caused by damage to the hypothalamus or pituitary gland and is a result of cranial surgery, infection, or tumor It is a condition in which an inadequate amount of anti-diuretic hormone is released and results in polyuria. A low specific gravity of 1.001 to 1.003 is a manifestation of diabetes insipidus (obtain a urine specific gravity) A nurse is caring for a patient who has had a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli which of the following reactions should the nurse anticipate when drawing a blood sample - In this posturing, the patient's posture rigidly extends and pronates in the 4 extremities and externally rotates their wrists and rigidly extends their arm it indicates severe brainstem injury in late neurologic decline A nurse in a rehab center is performing an assessment for a patient who is recovering from a left hemispheric stroke what should the nurse expect - The left hemisphere of the brain is usually the dominant side and is usually responsible for language this is always true for right handed clients and for the majority left-handed clients since this client is recovering from a left sided stroke the nurse should anticipate they will have aphasia and require speech therapy to establish communication L =language A nurse is assessing a client who has a high thoracic cord injury the nurse should identify which of the following findings as a manifestation of autonomic dysreflexia - Autonomic dysreflexia is a neurological emergency that can occur in patients who have cervical or thoracic spinal cord injury above the level T6 manifestations include a severe throbbing headache, flushing of the face and neck, bradycardia and extreme hypertension A nurse is assessing a patient who is Guillian Bare syndrome what should the nurse expect - It is characterized by a rapid onset of ascending weakness and paralysis starting at the lower extremities and can advance to the upper extremities A nurse is caring for a patient who is post op after a frontal craniotomy the nurse should place the client in which of the following positions - Semi Fowler's this is to prevent an increase in intracranial pressure they should position the patient with their head in midline and head of bed elevated 30° this permits blood flow to the brain while allowing Venus drainage therefore decreasing the postop risk of ICP A nurse is providing teaching to a class about TIAs what should the nurse include - It can proceed an ischemic stroke, they are considered a manifestation of advanced atherosclerositic disease and often proceeds an ischemic stroke manifestations may include loss of vision in one eye, inability to speak, transient hemiparesis, vertical diplopia, numbness and weakness A nurse is performing a neurological assessment for a patient who has a brain tumor which of the following would indicate that there is cranial nerve involvement - Dysphasia can occur as a result of damage to nerves by IX (glassopharyngeal) or X (Vegas) A nurse is teaching a patient who has a new diagnosis of simple partial seizures about auras, which of the following statements by the patient indicates an understanding of the teaching - An aura is a warning sign that a seizure is eminent, it can be similar to a hallucination and involve any of the senses For example, the client can report hearing bells seeing lights or smelling in odor A nurse in an acute care facility is preparing to admit a patient who has myasthenia gravis, which of the following supplies should the nurse place at the patient's bedside - This patient is at risk for aspiration because of progressive weakness of the oral pharyngeal muscles, this can cause muscle weakness due to the autoimmune disease that affects the acetylcholine receptors the nurse should place oxygen and oral nasal suction equipment at the bedside in event of aspiration or respiratory distress A nurse is assessing a patient who is unconscious and has rhythmic breathing pattern of rapid deep respirations, Followed by rapid shallow respirations, alternating with periods of apnea the nurse should document that the patient is experiencing what type of respirations - Cheyne stokes, this type of breathing can be the result of drug overdose, or increased intercranial pressure And can proceed death A nurse is providing teaching to a family of a patient with a new diagnosis of ALS the nurse should include in the teaching what type of findings as an early manifestation of ALS - This is a progressive neurogenic degenerative disease that involves the motor and nerve cells in the brain and the spinal cord causing muscle wasting, spasticity, and eventually paralysis

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