ATI MED-SURG NEUROSENSORY QUIZ
100% CORRECT!
,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. -ANSWER 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. -ANSWER 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 in a acute care facility is preparing to admit a client who has myasthenia gravis.
Which of the following supplies should the nurse place on the client's bedside?
A. Metered-dose inhaler
B. Continuous passive motion machine
C. External defibrillator pads
D. Oral-nasal suction equipment -ANSWER D. Oral-nasal suction equipment
Rationale: The client who has myasthenia gravis is at risk for aspiration because of
progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle
weakness due to an autoimmune disease that affects the acetylcholine receptors. The
nurse should place oxygen and oral-nasal suction equipment at the bedside in the event
of aspiration or respiratory distress. External defibrillator pads are used for a client who
has a cardiac dysrhythmia; however, they are not indicated for a client who has
myasthenia gravis. A continuous passive motion machine is used to provide continuous
motion of a joint for a client who is postoperative following joint surgery; however, it is
not indicated for a client who has myasthenia gravis. A metered-dose inhaler is used to
administer medications for a client who has asthma; however, it is not indicated for a
client who has myasthenia gravis.
A nurse is collecting data from a client who has a high-thoracic spinal cord injury. The
nurse should identify which of the following findings as a manifestation of autonomic
dysreflexia?
A. Flushing of the lower extremities
B. Hypotension
C. Tachycardia
D. Report of a headache -ANSWER D. Report of a headache
Rationale: Autonomic dysreflexia is a neurologic emergency that can occur in clients
who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic
dysreflexia can be triggered by a full bladder or distended rectum. Manifestations
include a severe, throbbing headache; flushing of the face and neck; bradycardia; and
extreme hypertension. Autonomic dysreflexia is a neurologic emergency that occurs in
clients who have a cervical or thoracic spinal cord injury above the level of T6.
Manifestations include bradycardia but not tachycardia. Autonomic dysreflexia is a
neurologic emergency that occurs in clients who have a cervical or thoracic spinal cord
injury above the level of T6. Manifestations include hypertension but not hypotension.
Autonomic dysreflexia is a neurologic emergency that can occur in clients who have a
cervical or thoracic spinal cord injury above the level of T6. Manifestations include
flushing above the level of injury and pallor below the level of injury.
100% CORRECT!
,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. -ANSWER 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. -ANSWER 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 in a acute care facility is preparing to admit a client who has myasthenia gravis.
Which of the following supplies should the nurse place on the client's bedside?
A. Metered-dose inhaler
B. Continuous passive motion machine
C. External defibrillator pads
D. Oral-nasal suction equipment -ANSWER D. Oral-nasal suction equipment
Rationale: The client who has myasthenia gravis is at risk for aspiration because of
progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle
weakness due to an autoimmune disease that affects the acetylcholine receptors. The
nurse should place oxygen and oral-nasal suction equipment at the bedside in the event
of aspiration or respiratory distress. External defibrillator pads are used for a client who
has a cardiac dysrhythmia; however, they are not indicated for a client who has
myasthenia gravis. A continuous passive motion machine is used to provide continuous
motion of a joint for a client who is postoperative following joint surgery; however, it is
not indicated for a client who has myasthenia gravis. A metered-dose inhaler is used to
administer medications for a client who has asthma; however, it is not indicated for a
client who has myasthenia gravis.
A nurse is collecting data from a client who has a high-thoracic spinal cord injury. The
nurse should identify which of the following findings as a manifestation of autonomic
dysreflexia?
A. Flushing of the lower extremities
B. Hypotension
C. Tachycardia
D. Report of a headache -ANSWER D. Report of a headache
Rationale: Autonomic dysreflexia is a neurologic emergency that can occur in clients
who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic
dysreflexia can be triggered by a full bladder or distended rectum. Manifestations
include a severe, throbbing headache; flushing of the face and neck; bradycardia; and
extreme hypertension. Autonomic dysreflexia is a neurologic emergency that occurs in
clients who have a cervical or thoracic spinal cord injury above the level of T6.
Manifestations include bradycardia but not tachycardia. Autonomic dysreflexia is a
neurologic emergency that occurs in clients who have a cervical or thoracic spinal cord
injury above the level of T6. Manifestations include hypertension but not hypotension.
Autonomic dysreflexia is a neurologic emergency that can occur in clients who have a
cervical or thoracic spinal cord injury above the level of T6. Manifestations include
flushing above the level of injury and pallor below the level of injury.
