ATI Neurosensory Practice Quiz Latest Update 2024 Answered 100%

A nurse reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure? - The client has a new tattoo - The client is unable to sit upright - The client has a history of peripheral vascular disease - The client has a pacemaker - ANSWER-The client has a pacemaker An MRI uses strong magnets and radio waves that are evaluated using computer technology to view three-dimensional images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medical implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures. A nurse is reinforcing teaching with a group of clients about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? - A TIA can cause irreversible hemiparesis - A TIA can be the result of cerebral bleeding - A TIA can cause cerebral edema - A TIA can precede to an ischemic stroke - ANSWER-A TIA can precede to an ischemic stroke 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. A nurse is collecting data from a client who has a new diagnosis of acute angle closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? - Multiple floaters - Flashes of light in front of the eye - Severe eye pain - Double vision - ANSWER-Severe eye pain Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headache, brow pain, and nausea and vomiting. 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 in the event of a seizure? - Reorient the client - Protect the client's head - Loosen constrictive clothing - Turn the client on his side - ANSWER-Protect the client's head 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 is to protect the client's head from injury. 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 high-pitched sound heard in the ear - Intermittent rapid eye movement - Itching on the external ear canal - Feeling of fullness in the ear - ANSWER-Feeling of fullness in the ear 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 nurse in a rehabilitation center is collecting data from a client who is recovering from a left hemisphere stroke. Which of the following findings should the nurse expect? - Reduced left-side motor function - Difficulty with speech - Impulsive behavior - Neglect of the left side of the body - ANSWER-Difficulty with speech The left hemisphere of the brain is usually the dominant side and is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication. A nurse is reinforcing teaching with the family of a client who has stage 2 Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching? - Place abstract pictures on the wall in the client's room. - Provide music for the client using headphones. - Reorient the client to reality frequently. - Limit choices offered to the client. - ANSWER-Limit choices offered to the client. Choices should be limited for the client who has stage II AD to reduce confusion and frustration. A nurse is collecting data from a client who is admitted to the facility for observation following a closed head injury. Which of the following data is the priority for the nurse to collect to detect a change in the client's neurologic status? - Vital signs - Body posture - Level of consciousness - Examination of pupils - ANSWER-Level of consciousness The nurse should apply the urgent vs. nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority because they pose more of a risk to the client. The nurse might also use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify the most urgent finding. Therefore, the priority assessment is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurologic status. A nurse is collecting data from a client following a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? - Widened pulse pressure - Tachycardia - Periorbital edema - Decrease in urine output - ANSWER-Widened pulse pressure A widening of the pulse pressure, the difference between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting. 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? - "You can expect your vision to return immediately after the procedure." - "You should avoid reading for 1 week." - "You can remove eye shields when you're sleeping." - "You should not lift objects that weigh more than 25 pounds." - ANSWER-"You should avoid reading for 1 week." The client should avoid reading and any activity that can cause rapid movement of the eye because of the risk for detachment of the retina. A nurse is reinforcing teaching with the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority? - Dysphagia - Emotional lability - Impaired speech - Self-care dependency - ANSWER-Dysphagia The nurse should apply the ABC priority-setting framework. A nurse is collecting data from a client who has a brain tumor. Which of the following findings indicates cranial nerve involvement? - Dysphagia - Positive Babinski sign - Decreased deep-tendon reflexes - Ataxia - ANSWER-Dysphagia Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).