ATI Medical/Surgical Neurosensory AH1 10/27/21
A nurse is collecting data from a client who has a brain tumor. Which of the following indicates cranial nerve involvement?
A. Dysphagia
B. Positive Babinski sign
C. Decreased deep-tendon reflexes
D. Ataxia
Rationale: Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X
(vagus). A positive Babinski sign, or the turning up of the toes upon plantar stimulation, is associated with an upper motor
neuron lesion. The cranial nerves primarily innervate the face, neck, and a few organs. Decreased deep-tendon reflexes
indicate impairment in the electrical conduction of spinal nerves that interfere with reflex arcs. The cranial nerves primarily
innervate the face, neck, and a few organs. Ataxia, or uncoordinated movements of the extremities, can indicate damage to
the cerebellum or motor pathways. The cranial nerves primarily innervate the face, neck, and a few organs.
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
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 Guillain-Barre syndrome. Which of the following findings should the nurse
expect?
A. Tonic-Clonic seizures
B. Report of a severe headache
C. Weakness of the lower extremities
D. Decreased level of consciousness
Rationale: Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder
of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower
extremities, and can advance to the upper extremities. Guillain-Barré syndrome is an inflammatory disorder of the peripheral
nerves. Decreased level of consciousness is not a manifestation of Guillain-Barré syndrome. Guillain-Barré syndrome is an
inflammatory disorder of the peripheral nerves. Severe headaches are not a manifestation of Guillain-Barré syndrome.
Guillain-Barré syndrome is an inflammatory disorder of the peripheral nerves. Tonic-clonic seizures are not a manifestation of
Guillain-Barré syndrome.
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
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.
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.
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
,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.
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.
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 reinforcing teaching with a client who has a new diagnosis of Meineres disease. Which of the following
instructions should the nurse include in the teaching?
A. Avoid bearing down
B. Increase caffeine intake
C. Avoid sudden movements
D. Increase sodium intake
Rationale: Meniere’s disease is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss,
and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations. The nurse
should instruct the client to reduce sodium intake and drink an evenly distributed amount of fluids throughout the day to
stabilize fluid levels in the body. The nurse should instruct the client to avoid caffeine and drink an evenly distributed amount
of fluids throughout the day to stabilize fluid levels in the body. Bearing down, or using the Valsalva maneuver, does not
increase the manifestations of Meniere’s disease.
A nurse is caring for a client who has 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?
A. The client rigidly extends his arms.
B. The client internally flexes his wrists.
C. The client curls into a fetal position.
D. The client internally rotates his legs.
Rationale: A client who exhibits a decerebrate posture rigidly extends and pronates his four extremities and externally rotates
his wrists. Decerebrate posturing indicates severe brain stem injury and late neurologic decline. A client who exhibits
decorticate posturing internally flexes his wrists and arms and extends and plantar flexes his legs. A fetal position is not a
manifestation of a decerebrate posture. A client who exhibits decorticate posturing flexes his arms with internal rotation of the
forearms and extends and plantar flexes his legs.
A nurse is collecting data from a client who has a new diagnosis of mastoiditis. Which of the following manifestations
should the nurse expect?
A. Swelling behind the affected ear
B. Facial drooping on the affected side
C. Nystagmus on the affected side
D. Pearly gray color of the affected eardrum
Rationale: Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include
swelling and pain behind the ear. Facial drooping can be a manifestation of a tympanoplasty, but it is not a manifestation of
mastoiditis. Bilateral nystagmus can be a manifestation of labyrinthitis, but it is not a manifestation of mastoiditis. A pearly
gray eardrum is an expected finding of a healthy eardrum. A red, thick eardrum is a manifestation of mastoiditis.
A nurse is reinforcing teaching with a class of new parents about otitis media. Which of the following manifestations should
the nurse include in the teaching?
A. A high-pitched sound heard in the ear
B. Intermittent rapid eye movement
C. Itching on the external canal
D. Feeling of fullness in the ear
Rationale: A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain,
a cracking sound when yawning or swallowing, and mild dizziness. A client who has external otitis can develop itching on the
ear canal. A client who has an inner ear disorder can develop nystagmus or rapid eye movement. A client who has otitis media
can develop a low-pitched sound in the affected ear.
A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following
, gray eardrum is an expected finding of a healthy eardrum. A red, thick eardrum is a manifestation of mastoiditis.
A nurse is reinforcing teaching with a class of new parents about otitis media. Which of the following manifestations should
the nurse include in the teaching?
A. A high-pitched sound heard in the ear
B. Intermittent rapid eye movement
C. Itching on the external canal
D. Feeling of fullness in the ear
Rationale: A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain,
a cracking sound when yawning or swallowing, and mild dizziness. A client who has external otitis can develop itching on the
ear canal. A client who has an inner ear disorder can develop nystagmus or rapid eye movement. A client who has otitis media
can develop a low-pitched sound in the affected ear.
A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following
instructions should the nurse include in the teaching?
A. Dry the ear canal with a cotton swab after swimming
B. Apply an ice pack to the ear to relieve pain
C. Instill a diluted solution into the ear after swimming
D. Irrigate the ear with cool tap water to clean
Rationale: External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from
swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops
to decrease bacteria and dry the external ear canal.
The client can gently irrigate the ear with warm tap water to remove cerumen after the inflammation is gone.
The client should not use cool water to irrigate the ear because it can cause nausea or dizziness. The client should apply a
warm, moist towel or a heating pad set at the lowest setting to the ear to reduce pain.
The client should not insert any object smaller than a finger into the ear because it can injure the delicate tissue of the external
ear canal, push cerumen further back against the tympanic membrane, or puncture the eardrum.
A nurse in a rehabilitation center is collecting data from a client who is recovering from a left-hemisphere stroke. What
finding should the nurse expect?
Difficulty with speech
A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain
at the onset of a migraine. What instructions should the nurse include in the teaching?
a. place a warm compress on your forehead
b. darken the lights - RN should instruct pt to lie down in dark room to reduce migraine pain.
c. light a scented candle
d. drink a caffeinated beverage
b. darken the lights
A nurse is collecting data from a client following a recent head injury. What finding should the nurse recognize as a
manifestation of increased intracranial pressure?
Widened pulse pressure - This is the diff btwn the systolic & diastolic which is a s/s of increased ICP. Other manifestations
include pupil changes, changes in LOC, and N/V.
Tachycardia can be a s/s of hypovolemia but bradycardia is a s/s of ICP.
Periorbital Edema - Can occur after eye trauma or craniotomy, but it is not a s/s of ICP.
Decrease in Urine Output - Can be a s/s of hypovolemia but is not a s/s of ICP.
A nurse is caring for a client who has closed head injury. The nurse should place the client in which position?
Semi-flowers - This position prevents an increase in ICP. It permits bld flow to the pts brain while allowing venous drainage,
thereby decrease in the postoperative risk of ICP.
Prone position is lying flat on abdomen, this increases ICP.
Trendelenburg can increase the ICP thus this position is contraindicated following a craniotomy.
Sim’s position is a side lying w/ flexion of hips and knee. Flexing hip or neck can cause increase in ICP.
A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease (AD). Which of the following
information should the nurse include in the teaching?
Limit choices offered to the client.
Rationale: Choices should be limited for the client who has stage II AD to reduce confusion and frustration.
Pt w/ stage II AD can become fearful of pictures of people or objects. The pts rom should not have pictures on the wall that
can confuse or scare the pt.
Noise can increase anxiety in a pt who has stage II AD. The pt’s environment should be quiet to reduce stress and promote
rest.
Pt w/ stage II AD can become agitated from reality orientation. Validation therapy can show acceptance of the pt’s feelings.
A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached
retina. Which of the following instructions should the nurse include in the teaching?
A nurse is collecting data from a client who has a brain tumor. Which of the following indicates cranial nerve involvement?
A. Dysphagia
B. Positive Babinski sign
C. Decreased deep-tendon reflexes
D. Ataxia
Rationale: Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X
(vagus). A positive Babinski sign, or the turning up of the toes upon plantar stimulation, is associated with an upper motor
neuron lesion. The cranial nerves primarily innervate the face, neck, and a few organs. Decreased deep-tendon reflexes
indicate impairment in the electrical conduction of spinal nerves that interfere with reflex arcs. The cranial nerves primarily
innervate the face, neck, and a few organs. Ataxia, or uncoordinated movements of the extremities, can indicate damage to
the cerebellum or motor pathways. The cranial nerves primarily innervate the face, neck, and a few organs.
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
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 Guillain-Barre syndrome. Which of the following findings should the nurse
expect?
A. Tonic-Clonic seizures
B. Report of a severe headache
C. Weakness of the lower extremities
D. Decreased level of consciousness
Rationale: Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder
of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower
extremities, and can advance to the upper extremities. Guillain-Barré syndrome is an inflammatory disorder of the peripheral
nerves. Decreased level of consciousness is not a manifestation of Guillain-Barré syndrome. Guillain-Barré syndrome is an
inflammatory disorder of the peripheral nerves. Severe headaches are not a manifestation of Guillain-Barré syndrome.
Guillain-Barré syndrome is an inflammatory disorder of the peripheral nerves. Tonic-clonic seizures are not a manifestation of
Guillain-Barré syndrome.
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
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.
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.
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
,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.
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.
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 reinforcing teaching with a client who has a new diagnosis of Meineres disease. Which of the following
instructions should the nurse include in the teaching?
A. Avoid bearing down
B. Increase caffeine intake
C. Avoid sudden movements
D. Increase sodium intake
Rationale: Meniere’s disease is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss,
and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations. The nurse
should instruct the client to reduce sodium intake and drink an evenly distributed amount of fluids throughout the day to
stabilize fluid levels in the body. The nurse should instruct the client to avoid caffeine and drink an evenly distributed amount
of fluids throughout the day to stabilize fluid levels in the body. Bearing down, or using the Valsalva maneuver, does not
increase the manifestations of Meniere’s disease.
A nurse is caring for a client who has 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?
A. The client rigidly extends his arms.
B. The client internally flexes his wrists.
C. The client curls into a fetal position.
D. The client internally rotates his legs.
Rationale: A client who exhibits a decerebrate posture rigidly extends and pronates his four extremities and externally rotates
his wrists. Decerebrate posturing indicates severe brain stem injury and late neurologic decline. A client who exhibits
decorticate posturing internally flexes his wrists and arms and extends and plantar flexes his legs. A fetal position is not a
manifestation of a decerebrate posture. A client who exhibits decorticate posturing flexes his arms with internal rotation of the
forearms and extends and plantar flexes his legs.
A nurse is collecting data from a client who has a new diagnosis of mastoiditis. Which of the following manifestations
should the nurse expect?
A. Swelling behind the affected ear
B. Facial drooping on the affected side
C. Nystagmus on the affected side
D. Pearly gray color of the affected eardrum
Rationale: Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include
swelling and pain behind the ear. Facial drooping can be a manifestation of a tympanoplasty, but it is not a manifestation of
mastoiditis. Bilateral nystagmus can be a manifestation of labyrinthitis, but it is not a manifestation of mastoiditis. A pearly
gray eardrum is an expected finding of a healthy eardrum. A red, thick eardrum is a manifestation of mastoiditis.
A nurse is reinforcing teaching with a class of new parents about otitis media. Which of the following manifestations should
the nurse include in the teaching?
A. A high-pitched sound heard in the ear
B. Intermittent rapid eye movement
C. Itching on the external canal
D. Feeling of fullness in the ear
Rationale: A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain,
a cracking sound when yawning or swallowing, and mild dizziness. A client who has external otitis can develop itching on the
ear canal. A client who has an inner ear disorder can develop nystagmus or rapid eye movement. A client who has otitis media
can develop a low-pitched sound in the affected ear.
A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following
, gray eardrum is an expected finding of a healthy eardrum. A red, thick eardrum is a manifestation of mastoiditis.
A nurse is reinforcing teaching with a class of new parents about otitis media. Which of the following manifestations should
the nurse include in the teaching?
A. A high-pitched sound heard in the ear
B. Intermittent rapid eye movement
C. Itching on the external canal
D. Feeling of fullness in the ear
Rationale: A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain,
a cracking sound when yawning or swallowing, and mild dizziness. A client who has external otitis can develop itching on the
ear canal. A client who has an inner ear disorder can develop nystagmus or rapid eye movement. A client who has otitis media
can develop a low-pitched sound in the affected ear.
A nurse is reinforcing teaching with an adolescent client who has recurrent external otitis. Which of the following
instructions should the nurse include in the teaching?
A. Dry the ear canal with a cotton swab after swimming
B. Apply an ice pack to the ear to relieve pain
C. Instill a diluted solution into the ear after swimming
D. Irrigate the ear with cool tap water to clean
Rationale: External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from
swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops
to decrease bacteria and dry the external ear canal.
The client can gently irrigate the ear with warm tap water to remove cerumen after the inflammation is gone.
The client should not use cool water to irrigate the ear because it can cause nausea or dizziness. The client should apply a
warm, moist towel or a heating pad set at the lowest setting to the ear to reduce pain.
The client should not insert any object smaller than a finger into the ear because it can injure the delicate tissue of the external
ear canal, push cerumen further back against the tympanic membrane, or puncture the eardrum.
A nurse in a rehabilitation center is collecting data from a client who is recovering from a left-hemisphere stroke. What
finding should the nurse expect?
Difficulty with speech
A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain
at the onset of a migraine. What instructions should the nurse include in the teaching?
a. place a warm compress on your forehead
b. darken the lights - RN should instruct pt to lie down in dark room to reduce migraine pain.
c. light a scented candle
d. drink a caffeinated beverage
b. darken the lights
A nurse is collecting data from a client following a recent head injury. What finding should the nurse recognize as a
manifestation of increased intracranial pressure?
Widened pulse pressure - This is the diff btwn the systolic & diastolic which is a s/s of increased ICP. Other manifestations
include pupil changes, changes in LOC, and N/V.
Tachycardia can be a s/s of hypovolemia but bradycardia is a s/s of ICP.
Periorbital Edema - Can occur after eye trauma or craniotomy, but it is not a s/s of ICP.
Decrease in Urine Output - Can be a s/s of hypovolemia but is not a s/s of ICP.
A nurse is caring for a client who has closed head injury. The nurse should place the client in which position?
Semi-flowers - This position prevents an increase in ICP. It permits bld flow to the pts brain while allowing venous drainage,
thereby decrease in the postoperative risk of ICP.
Prone position is lying flat on abdomen, this increases ICP.
Trendelenburg can increase the ICP thus this position is contraindicated following a craniotomy.
Sim’s position is a side lying w/ flexion of hips and knee. Flexing hip or neck can cause increase in ICP.
A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease (AD). Which of the following
information should the nurse include in the teaching?
Limit choices offered to the client.
Rationale: Choices should be limited for the client who has stage II AD to reduce confusion and frustration.
Pt w/ stage II AD can become fearful of pictures of people or objects. The pts rom should not have pictures on the wall that
can confuse or scare the pt.
Noise can increase anxiety in a pt who has stage II AD. The pt’s environment should be quiet to reduce stress and promote
rest.
Pt w/ stage II AD can become agitated from reality orientation. Validation therapy can show acceptance of the pt’s feelings.
A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached
retina. Which of the following instructions should the nurse include in the teaching?
