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Med-Surg III: Neuro - Ch. 21: The Neurologic System, Ch. 22: Care of Patients with Head & Spinal Cord Injuries, Ch. 23: Care of Patients with Brain Disorders, & Ch. 24: Care of Patients with Peripheral Nerve & Degenerative Neurologic Disorders Questions a€10,36
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Med-Surg III: Neuro - Ch. 21: The Neurologic System, Ch. 22: Care of Patients with Head & Spinal Cord Injuries, Ch. 23: Care of Patients with Brain Disorders, & Ch. 24: Care of Patients with Peripheral Nerve & Degenerative Neurologic Disorders Questions a
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Med-Surg III: Neuro - Ch. 21: The Neurologic System, Ch. 22: Care of Patients with Head & Spinal Cord Injuries, Ch. 23: Care of Patients with Brain Disorders, & Ch. 24: Care of Patients with Peripheral Nerve & Degenerative Neurologic Disorders Questions and Answers 100% Solved 2024/2025
a nurse is caring for a client who is postprocedur
postprocedure appropriately label tubes with pat
a monitor for hypotension b provide an emesis ba
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Med-Surg III: Neuro - Ch. 21: The
Neurologic System, Ch. 22: Care of
Patients with Head & Spinal Cord
Injuries, Ch. 23: Care of Patients with
Brain Disorders, & Ch. 24: Care of
Patients with Peripheral Nerve &
Degenerative Neurologic Disorders
A nurse is caring for a client who is postprocedure following lumbar puncture & reports a
throbbing headache when sitting upright. Which of the following actions should the nurse take?
(SATA)
a. Use the Glasgow Coma Scale to evaluate the client.
b. Assist the client to a supine position.
c. Administer opioid medication
d. Encourage the client to increase fluid intake.
e. Remove the bandage on the client's puncture site. - ANS• Place the patient in a supine
position
• Administer an opioid for pain
• Encourage the patient to increase fluid intake
Postprocedure: Appropriately label tubes with patient data & transport them to the laboratory
immediately. Keep patient flat in bed to reduce headache for 1 hour or longer after procedure &
encourage fluid intake unless contraindicated. Observe the site for signs of drainage &
inflammation.
Ch. 21, pg. 480 (Table 21-6)
Med-Surg ATI: Ch. 3, pg. 21 & 23
A nurse is contributing to the plan of care for a client who has bacterial meningitis. Which of the
following interventions should the nurse include? (SATA)
a. Monitor for hypotension
b. Provide an emesis basin at the bedside
c. Administer antipyretic medication
,d. Perform a skin assessment
e. Keep the head of the bed flat - ANS• Provide an emesis basin at the bedside
• Administer antipyretic medication
• Perform a skin assessment
Med-Surg ATI: Ch. 5, pg. 32 & 33
A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the
following findings should the nurse expect? (SATA)
a. Impulse control difficulty
b. Left hemiplegia
c. Loss of depth perception
d. Aphasia
e. Lack of situational awareness - ANS• Impulse control difficulty
• Left hemiplegia
• Loss of depth perception
• Lack of situational awareness
PHYSICAL FINDINGS:
Manifestations vary based on the area of the brain that is deprived of oxygenated blood:
*The LEFT cerebral hemisphere* is responsible for language, mathematics skills, & analytic
thinking.
• Expressive & receptive aphasia (inability to speak & understand language)
• Right extremity hemiplegia (paralysis) or hemiparesis (weakness).
• Slow cautious behavior
• Depression, anger, & quick to become frustrated
• Visual changes, such as hemianopsia (loss of visual field in one or both eyes)
*The RIGHT cerebral hemisphere* is responsible for visual & spatial awareness &
propioception.
• Altered perception of deficits (overestimation of abilities)
• Loss of depth perception
• Poor impulse control & judgment
• Inability to solve problems
• Emotional lability
• Left hemiplegia, or hemiparesis
• Visual changes, such as hemianopsia
Med-Surg ATI: Ch. 9, pg. 54 & 58
A nurse is contributing to a plan of care for the nutritional needs of a client who has stage IV
Parkinson's Disease (PD). Which nursing actions should the nurse include in the plan of care?
(SATA)
a. Provide 3 large balanced meals daily.
, b. Record diet & fluid intake only.
c. Document weight every other week.
d. Place the client in Fowler's position to eat.
e. Offer nutritional supplements between meals. - ANS• Record diet & fluid intake daily.
• Offer nutritional supplements between meals.
NURSING CARE:
• Consult the dietician for appropriate diet, which often includes semisolid foods & thickened
liquids.
• Document the client's weight at least weekly.
• Keep a dietary intake log.
• Encourage fluids & document intake.
• Provide smaller, more frequent meals. (Six)
• Sit the client upright to eat or drink, & keep upright for 1 hr following meals.
• Consult with OT for adaptive eating devices.
• Evaluate the need for high-calorie, high-protein supplements to maintain client's weight.
Med-Surg ATI: Ch. 7, pg. 41 & 44
A nurse is collecting data from a client who has increased intracranial pressue (ICP). Which of
the following findings should the nurse expect? (SATA)
a. Disoriented to time & place
b. Restlessness & irritability
c. Unequal pupils
d. ICP 15 mm Hg
e. Headache - ANS• Disoriented to time & place
• Restlessness & irritability
• Unequal pupils
• Headache
MANIFESTATIONS OF INCREASED ICP:
• Severe headache, N/V
• Deteriorating LOC, restlessness, irritability
• Dilated or pinpoint nonreactive pupils
• Cranial nerve dysfunction
• Alteration in breathing pattern (Cheyne-Stokes respirations, central neurogenic
hyperventilation, apnea)
• Deterioration in motor function, abnormal posturing, (decerebrate, decorticate, flaccidity)
• Cushing's triad is a late finding characterized by severe hypertension with a widening pulse
pressure (systolic-diastolic) & bradycardia
• Seizures
Med-Surg ATI: Ch. 12, pg. 72 & 76
Ch. 22, pg. 506; Figure 22-7
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