Prioritization_Chapter_7_Neurological_Revised_20_August_2022

Chapter 7 Neurological 1. The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a stroke who has a platelet level of 250,000 μ/L. 2. The client with a seizure disorder who has a divalproex (Depakote) level of 75 μg/mL. 3. The client with multiple sclerosis on prednisone who has a glucose level of 208 mg/dL. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has serum levels of 24 mg/dL. 2. The nurse is administering medications for clients on a neurological unit. Which medication should the nurse administer first? 1. A pain medication to a client complaining of a headache rated an 8 on 1 to 10 pain scale. 2. A steroid to the client experiencing an acute exacerbation of multiple sclerosis. 3. An anticholinesterase medication to a client diagnosed with myasthenia gravis. 4. An antacid to a client with pyrosis who has called several times over the intercom. 3. The nurse has just received the shift report. Which client should the nurse assess first? 1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. 2. The client with a C-6 spinal cord injury who has autonomic dysreflexia. 3. The client with Parkinson’s disease who is experiencing “pill rolling.” 4. The client with Huntington’s disease who has writhing, twisting movements of the face. 4. The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The UAP places the gait belt around the client’s waist prior to ambulating. 2. The UAP places the client on the abdomen with the client’s head to the side. 3. The UAP places her hand under the client’s right axilla to help the client move up in bed. 4. The UAP praises the client for performing activities of daily living independently. 1. The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain. 4. The client with Alzheimer’s disease who is wandering in the halls. 6. The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate for the case manager to make at this time? 1. Inpatient rehabilitation unit. 2. Home healthcare agency. 3. Long-term care facility. 4. Outpatient therapy center. 7. The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the nurse assign to the LPN? 1. Feed the client who is being allowed to eat for the first time. 2. Administer the client’s anticoagulant subcutaneously. 3. Check the client’s neurological signs and limb movement. 4. Teach the client to turn the head and tuck the chin to swallow. 8. The nurse is caring for a client diagnosed with Alzheimer’s disease. Which nursing tasks should not be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Check the client’s skin under the restraints. 2. Administer the client’s antipsychotic medication. 3. Perform the client’s morning hygiene care. 4. Ambulate the client to the bathroom. 5. Obtain the client’s routine vital signs. 9. The nurse on the surgical unit is working with an unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP? 1. Change an abdominal dressing on a client who is 2 days postoperative. 2. Check the client’s IV insertion site on the right arm. 3. Monitor vital signs on a client who has just returned from surgery. 4. Escort a client who has been discharged to the client’s vehicle. 10. Which client should the charge nurse assess first after receiving the change-of-shift report? 1. The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute. 2. The client with an L-4 SCI who is frightened about being transferred to the rehabilitation unit. 3. The client with an L-2 SCI who is complaining of a headache and feeling very hot all of a sudden. 4. The client with a C-4 SCI who is on a ventilator and has a pulse oximeter reading of 98%. 11. The client with a C-6 spinal cord injury (SCI) comes to the emergency department complaining of a throbbing headache and has a B/P of 200/120. Which intervention should the nurse implement first? 1. Place the client on a telemetry unit. 2. Complete a neurological assessment. 3. Insert an indwelling urinary catheter. 4. Request a STAT CT scan on the head. ............................................continued.........................................