ATI Med-Surg Neurosensory Quiz Exam Questions With 100% Correct Answers.

A nurse is reinforcing discharge teaching with the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first during the event of a seizure? A. Reorient the client. B. Protect the client's head. C. Loosen constrictive clothing. D. Turn the client on his side. - B. Protect the client's head Rationale: The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The client is at greatest risk for injury from hitting his head; therefore, the first action the nurse should take is to protect the client's head from injury. The family should reorient the client as he regains consciousness following a seizure; however, another action is the priority. The family should loosen constrictive clothing to protect the client from injury during a seizure; however, another action is the priority. The family should turn the client on his side to protect the client from injury during a seizure; however, another action is the priority. A nurse is reinforcing teaching with a group of client's about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis. B. A TIA can be the result of cerebral bleeding. C. A TIA can cause cerebral edema. D. A TIA can precede an ischemic stroke. - D. A TIA can precede an ischemic stroke. Rationale: TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include loss of vision in one eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness. TIAs do not produce edema of the cerebrum.Cerebral edema can be the result of a stroke. A hemorrhagic stroke can be the result of cerebral bleeding. TIAs are caused by a temporary reduction of oxygen supply to the brain, such as from a thromboembolism or cerebral vasospasm. TIAs are brief episodes of a neurologic deficit that last less than 24 hr after onset without any permanent disabilities. A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. Widened pulse pressure B. Tachycardia C. Periorbital edema D. Decrease in urine output - A. Widened pulse pressure