Med-Surg ATI Neurosensory Quiz Flashcards 2024

A nurse perfoms a neurologic assessment on a client with a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? A: Dysphagia B: Positive Babinski sign C: Decreased deep tendon reflexes D: Ataxia A: Dysphagia (difficulty swallowing may occur as a result of the cranial nerves IX -glossopharyngeal & V -vagus nerve.) A nurse is assessing a client who was just admitted to the hospital for observation following a closed-head injury. Which of the following is the most essential nursing assessment to detect early signs of a worsening condition? A: Vital signs B: Body posture C: LOC D: Focal neurological exam C: LOC A bolus of mannitol (Osmitrol) is ordered for a client with a closed-head injury showing manifestations of increasing intracranial pressure. Prior to administration, assessment shows: UO 40 mL/hr, apical HR 88/min, and the pupils equal and reactive. The client is sleepy but easily aroused. After administering mannitol to the client, which of the following should indicate to the nurse that the medication is having the desired effect? A: UO is 100 mL/hr B: Pupils are dilated C: HR is 62/min D: Client is difficult to rouse A: UO is 100 mL/hr (osmotic diuretic used to ↑ UO and ↓ cerebral edema) A nurse is caring for a client who is post-op following a craniotomy to evacuate a subdural hematoma. The nurse notes the client's UO is greater each hour than the previous hour; from 1800 to 1900 the UO was 200 mL, from 1900 to 2000 the UO was 400 mL, and from 2000 to 2100 the UO was 600 mL. The nurse informs the surgeon and anticipates that the lab value that will be prescribed at this time is: A: Blood Urea Nitrogen B: Blood sugar C: Urine ketones D: Specific gravity D: Specific gravity A nurse is reading the results of a lumbar puncture (LP) performed on a client suspected of having bacterial meningitis. Which of the following findings should the nurse recognize as being consistent with this diagnosis? A: Elevated glucose B: Elevated protein C: Presence of RBC D: Presence of D-dimer B: Elevated protein (typically CSF has a higher proportion of glucose than protein, an elevated protein is consistent with meningitis) A client has been diagnosed with acute angle closure glaucoma. The nurse should expect the client to report A: Showers of floaters B: Flashes of light across the eye C: Eye pain and blurred vision D: Double vision C: Eye pain and blurred vision Which of the following statements, made by a client who had an IOL implant this morning, should indicate to a nurse a proper understanding of discharge instructions? A: I will sleep in my recliner tonight. B: I will avoid bending over or coughing. C: I will follow a low-salt and caffeine restricted diet. D: I will report any signs of photophobia to my Dr. B: I will avoid bending over or coughing. A nurse is caring for a client with Guillain-Barre syndrome. Upon assessment, the nurse should anticipate that the client will exhibit which of the following? A: Tonic-clonic seizures B: Complaints of a severe headache and nausea C: Weakness of the lower extremities D: Decreased level of consciousness C: Weakness of the lower extremities. A nurse understands that a client with a seizure disorder, who frequently experiences an aura is describing a: